=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184305526
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IRVING RADIOLOGY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2023
-----------------------------------------------------
Last Update Date | 07/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4011 S MONROE MEDICAL PARK BLVD
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-309-0602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13690 EAGLE RIDGE DR
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-1864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-309-0602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WINSTON DACOSTA IRVING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-935-0770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------