Healthcare Provider Details

I. General information

NPI: 1114555430
Provider Name (Legal Business Name): ETHAN RADZINSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 S BASCOM AVE
SAN JOSE CA
95128-2604
US

IV. Provider business mailing address

751 S BASCOM AVE
SAN JOSE CA
95128-2604
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-5110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number177745
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: