Healthcare Provider Details

I. General information

NPI: 1275762379
Provider Name (Legal Business Name): VADIM CHUDNOVSKY M D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 01/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1743 S CLAUDINA WAY
ANAHEIM CA
92805-6544
US

IV. Provider business mailing address

1743 S CLAUDINA WAY
ANAHEIM CA
92805-6544
US

V. Phone/Fax

Practice location:
  • Phone: 714-635-0880
  • Fax: 714-635-0890
Mailing address:
  • Phone: 714-635-0880
  • Fax: 714-635-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0207X
TaxonomyMobile Mammography Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. VADIM CHUDNOVSKY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-635-0880