Healthcare Provider Details

I. General information

NPI: 1477693513
Provider Name (Legal Business Name): PET IMAGING OF SAN JOSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 MOORPARK AVE SUITE 220
SAN JOSE CA
95128-2654
US

IV. Provider business mailing address

2211 MOORPARK AVE SUITE 220
SAN JOSE CA
95128-2654
US

V. Phone/Fax

Practice location:
  • Phone: 408-297-8844
  • Fax: 408-297-8220
Mailing address:
  • Phone: 408-297-8844
  • Fax: 408-297-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number6846-43
License Number StateCA

VIII. Authorized Official

Name: BIJAN FARHANGUI
Title or Position: CEO, PRESIDENT
Credential:
Phone: 408-297-8844