Healthcare Provider Details

I. General information

NPI: 1629294681
Provider Name (Legal Business Name): PHYSICIANS IMAGING-MT DORA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 LAKE CENTER DR
MOUNT DORA FL
32757-2364
US

IV. Provider business mailing address

P.O. BOX 4610
LAKE CHARLES LA
70606-4610
US

V. Phone/Fax

Practice location:
  • Phone: 352-383-3716
  • Fax: 352-383-7457
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ELIAS J GERTH
Title or Position: OPERATING MANAGER
Credential: M.D.
Phone: 305-295-1242