Healthcare Provider Details

I. General information

NPI: 1104265396
Provider Name (Legal Business Name): SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 SANTA FE DR
ENCINITAS CA
92024-5142
US

IV. Provider business mailing address

PO BOX 23540
SAN DIEGO CA
92193-3540
US

V. Phone/Fax

Practice location:
  • Phone: 760-633-6501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: NORMAN C. CHEN
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 858-565-0950