Healthcare Provider Details

I. General information

NPI: 1295088334
Provider Name (Legal Business Name): SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15525 POMERADO RD SUITE E2
POWAY CA
92064-2435
US

IV. Provider business mailing address

PO BOX 23540
SAN DIEGO CA
92193-3540
US

V. Phone/Fax

Practice location:
  • Phone: 858-521-0031
  • Fax:
Mailing address:
  • Phone: 858-565-0950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

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