MEDICARE: CARDIOVASCULAR DIAGNOSTIC CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician	11314R	LA
2	207RC0000X	Cardiovascular Disease Physician	11314R	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497894620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDIOVASCULAR DIAGNOSTIC CENTER

Provider Business Mailing Address
First Line	:	402 MCMILLAN RD
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71291-5326
Country	:	US
Telephone Number	:	318-338-3540
Fax Number	:	318-335-3542

Provider Business Practice Location Address
First Line	:	402 MCMILLAN RD
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71291-5326
Country	:	US
Telephone Number	:	318-338-3540
Fax Number	:	318-335-3542

Authorized Official
Title or Position	:	OWNER
Name	:	VIRGINIA Y GONZALEZ
Credential	:	M.D.
Telephone Number	:	318-338-3540

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	12/30/2012

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