Provider Demographics
NPI:1154343739
Name:PROSPECT DIAGNOSTIC IMAGING
Entity type:Organization
Organization Name:PROSPECT DIAGNOSTIC IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GUMBARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-264-7999
Mailing Address - Street 1:385 MAIN ST S
Mailing Address - Street 2:UNION SQUARE BLDG #1 C/O NVRA
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-4240
Mailing Address - Country:US
Mailing Address - Phone:203-264-7999
Mailing Address - Fax:203-264-7477
Practice Address - Street 1:166 WATERBURY ROAD
Practice Address - Street 2:RTE 69
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712
Practice Address - Country:US
Practice Address - Phone:203-758-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAUGATUCK VALLEY RADIOLOGICAL ASSOC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-24
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004221363Medicaid
CT004221363Medicaid