Healthcare Provider Details

I. General information

NPI: 1255844106
Provider Name (Legal Business Name): COMPREHENSIVE DIAGNOSTIC IMAGING OF WISCONSIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W LAYTON AVE STE 20
MILWAUKEE WI
53221-5400
US

IV. Provider business mailing address

2500 W LAYTON AVE STE 20
MILWAUKEE WI
53221-5400
US

V. Phone/Fax

Practice location:
  • Phone: 262-261-9423
  • Fax: 414-539-4185
Mailing address:
  • Phone: 262-261-9423
  • Fax: 414-539-4185

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 Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES MAZZULLA
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 414-281-2100