Provider Demographics
NPI:1063781334
Name:WEST TEXAS IMAGING CENTER PA
Entity type:Organization
Organization Name:WEST TEXAS IMAGING CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAJJADUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ISLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-335-8400
Mailing Address - Street 1:320 N MUSKINGUM AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5152
Mailing Address - Country:US
Mailing Address - Phone:432-335-8400
Mailing Address - Fax:
Practice Address - Street 1:320 N MUSKINGUM AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5152
Practice Address - Country:US
Practice Address - Phone:432-335-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST TEXAS IMAGING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-15
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty