MEDICARE: CALIFORNIA DIAGNOSTIC IMAGING CENTER A MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00081546	OTHER	CA	RAIL ROAD MEDICARE GRP #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	ZZZ07258Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1396737474
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALIFORNIA DIAGNOSTIC IMAGING CENTER A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	BOX 5010
Second Line	:
City	:	GLENDORA
State	:	CA
Zip	:	91740-0735
Country	:	US
Telephone Number	:	626-915-5181
Fax Number	:	626-331-2313

Provider Business Practice Location Address
First Line	:	828 S GRAND AVE
Second Line	:	STE 104
City	:	GLENDORA
State	:	CA
Zip	:	91740-4856
Country	:	US
Telephone Number	:	626-915-5181
Fax Number	:	626-331-2313

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID J UNDERWOOD
Credential	:	MD
Telephone Number	:	626-339-5464

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	10/18/2017

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