Healthcare Provider Details

I. General information

NPI: 1740305846
Provider Name (Legal Business Name): DELTA RADIOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 S FAIRMONT AVE
LODI CA
95240-5112
US

IV. Provider business mailing address

PO BOX 15498
SACRAMENTO CA
95851-0498
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-7810
  • Fax:
Mailing address:
  • Phone: 559-455-4000
  • Fax: 559-455-4007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DANIEL WOLCOTT
Title or Position: PRESIDENT
Credential:
Phone: 209-339-7560