Healthcare Provider Details

I. General information

NPI: 1043229271
Provider Name (Legal Business Name): DELTA RADIOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W VINE ST SUITE 15
LODI CA
95240-5137
US

IV. Provider business mailing address

PO BOX 15498
SACRAMENTO CA
95851-0498
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-4416
  • Fax: 209-371-0119
Mailing address:
  • Phone: 559-455-4000
  • Fax: 559-455-4007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TERRY GOLDBERG
Title or Position: CEO
Credential:
Phone: 209-334-4416