Healthcare Provider Details

I. General information

NPI: 1164487799
Provider Name (Legal Business Name): CARDIOVASCULAR IMAGING MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 04/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15107 VANOWEN ST
VAN NUYS CA
91405-4542
US

IV. Provider business mailing address

PO BOX 10076
VAN NUYS CA
91410-0076
US

V. Phone/Fax

Practice location:
  • Phone: 818-782-5041
  • Fax:
Mailing address:
  • Phone: 805-578-8300
  • Fax: 805-578-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN S TSAKONAS
Title or Position: PRESIDENT
Credential: MD
Phone: 818-782-5041