Healthcare Provider Details

I. General information

NPI: 1891747200
Provider Name (Legal Business Name): DIGITAL & RADIOLOGIC IMAGING ASSOCIATES INC. A MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17100 EUCLID ST
FOUNTAIN VALLEY CA
92708-4004
US

IV. Provider business mailing address

PO BOX 3148
MISSION VIEJO CA
92690-1148
US

V. Phone/Fax

Practice location:
  • Phone: 714-966-8041
  • Fax:
Mailing address:
  • Phone: 949-348-1105
  • Fax: 949-348-1210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ELLIOTT J. WAGNER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-348-1105