Healthcare Provider Details

I. General information

NPI: 1356305767
Provider Name (Legal Business Name): FLORIDA DIAGNOSTIC IMAGING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 BABCOCK ST NE SUITE 5
PALM BAY FL
32905-4637
US

IV. Provider business mailing address

5201 BABCOCK ST NE SUITE 5
PALM BAY FL
32905-4637
US

V. Phone/Fax

Practice location:
  • Phone: 321-676-5323
  • Fax: 321-951-9253
Mailing address:
  • Phone: 321-676-5323
  • Fax: 321-951-9253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberHCC5282
License Number StateFL

VIII. Authorized Official

Name: DR. IAN LANDIS
Title or Position: PRESIDENT
Credential: DO
Phone: 321-676-5323