Healthcare Provider Details

I. General information

NPI: 1326086703
Provider Name (Legal Business Name): TUSTIN TELERADIOLOGY MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 01/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13422 NEWPORT AVE SUITE I
TUSTIN CA
92780-3746
US

IV. Provider business mailing address

13422 NEWPORT AVE SUITE I
TUSTIN CA
92780-3746
US

V. Phone/Fax

Practice location:
  • Phone: 714-665-6900
  • Fax: 714-665-6904
Mailing address:
  • Phone: 714-665-6900
  • Fax: 714-665-6904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberG74535
License Number StateCA

VIII. Authorized Official

Name: DR. THOMAS L ATLAS
Title or Position: OWNER
Credential: MD
Phone: 714-665-6900