Healthcare Provider Details

I. General information

NPI: 1336161918
Provider Name (Legal Business Name): DIAGNOSTIC IMAGING ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 WEST MAIN STREET
WATERBURY CT
06708
US

IV. Provider business mailing address

385 MAIN ST SOUTH C/O NVRA UNION SQUARE BUILDING #1
SOUTHBURY CT
06488
US

V. Phone/Fax

Practice location:
  • Phone: 203-574-1311
  • Fax:
Mailing address:
  • Phone: 203-264-7999
  • Fax: 203-264-7477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT GUMBARDO
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 203-264-7999