=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306085949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UDKOFF MEDICAL IMAGING CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2009
-----------------------------------------------------
Last Update Date | 04/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1265 CANYON RIM CIR
-----------------------------------------------------
City | WESTLAKE VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91362-5228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-865-1963
-----------------------------------------------------
Fax | 818-865-9767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1265 CANYON RIM CIR
-----------------------------------------------------
City | WESTLAKE VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91362-5228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-865-1963
-----------------------------------------------------
Fax | 818-865-9767
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RANON CHARLES UDKOFF
-----------------------------------------------------
Credential | M.D., PH.D.
-----------------------------------------------------
Telephone | 818-865-1963
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------