Healthcare Provider Details

I. General information

NPI: 1285899021
Provider Name (Legal Business Name): KODIAK DIAGNOSTIC IMAGING, PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 E REZANOF DR
KODIAK AK
99615-6602
US

IV. Provider business mailing address

384 LILLY DR
KODIAK AK
99615-7115
US

V. Phone/Fax

Practice location:
  • Phone: 907-539-8997
  • Fax:
Mailing address:
  • Phone: 907-486-2466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4924
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CARLOS E RIO
Title or Position: PRESIDENT
Credential: MD
Phone: 907-486-2466