Healthcare Provider Details

I. General information

NPI: 1124530761
Provider Name (Legal Business Name): RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 09/16/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3016 DYER BOULEVARD
KISSIMMEE FL
34741
US

IV. Provider business mailing address

2125 CRYSTAL GROVE DR
LAKELAND FL
33801-6875
US

V. Phone/Fax

Practice location:
  • Phone: 941-782-9456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTHA LIMA
Title or Position: TREASURER
Credential: MD
Phone: 863-688-2334