Basic Information
| Provider Information | |||||||||
| NPI: | 1568906790 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLNESS DIAGNOSTIC IMAGING PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1608 59TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112042129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188727585 | ||||||||
| FaxNumber: | 7188727591 | ||||||||
| Practice Location | |||||||||
| Address1: | 1608 59TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112042129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188727585 | ||||||||
| FaxNumber: | 7188727591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2016 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | GREENBERG | ||||||||
| AuthorizedOfficialFirstName: | ODED | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 7188727585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 178096 | 01 | NY | STATE LICENSE | OTHER |