Basic Information
| Provider Information | |||||||||
| NPI: | 1740721661 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | I V RADIOLOGY MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | IMPERIAL VALLEY RADIOLOGY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | NEWBURY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913190009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594554009 | ||||||||
| FaxNumber: | 9165330313 | ||||||||
| Practice Location | |||||||||
| Address1: | 162 VIA MONTE DORO | ||||||||
| Address2: | |||||||||
| City: | REDONDO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902776440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594554009 | ||||||||
| FaxNumber: | 9165330313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2017 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PASCUAL | ||||||||
| AuthorizedOfficialFirstName: | RAMON | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5594554009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.