Healthcare Provider Details

I. General information

NPI: 1548297088
Provider Name (Legal Business Name): SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 MEDICAL CENTER CT SAN DIEGO IMAGING - CHULA VISTA
CHULA VISTA CA
91911-6600
US

IV. Provider business mailing address

PO BOX 23540
SAN DIEGO CA
92193-3540
US

V. Phone/Fax

Practice location:
  • Phone: 619-397-6577
  • Fax: 619-397-5182
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD W PADELFORD
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 858-565-0950