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General NPI Number Information
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NPI Number | 1174020226
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Entity Type | Organization
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Legal Business Name | QUEENS DIAGNOSTIC RADIOLOGY, P.C.
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Dates
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Enumeration Date | 04/06/2018
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 25302 ROCKAWAY BLVD STE B
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City | ROSEDALE
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State | NY
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Zip | 11422-3114
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Country | US
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Telephone | 718-764-2222
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Fax | 516-666-8655
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Provider Business Mailing Address
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Address Line | 25302 ROCKAWAY BLVD STE B
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City | ROSEDALE
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State | NY
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Zip | 11422-3114
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Country | US
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Telephone | 718-764-2222
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Fax | 516-666-8655
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK J LODESPOTO
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Credential | MD
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Telephone | 718-764-2222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 171063
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License Number State | NY
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