Provider Demographics
NPI:1225069883
Name:SAN DIEGO DIAGONSTIC RADIOLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SAN DIEGO DIAGONSTIC RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-565-0950
Mailing Address - Street 1:PO BOX 23540
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-3540
Mailing Address - Country:US
Mailing Address - Phone:858-565-0950
Mailing Address - Fax:858-244-1100
Practice Address - Street 1:751 MEDICAL CENTER CT
Practice Address - Street 2:SHARP CHULA VISTA MEDICAL CENTER
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6617
Practice Address - Country:US
Practice Address - Phone:619-482-3639
Practice Address - Fax:619-482-4032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1982005164207U00000X, 207UN0901X, 207UN0902X, 2085P0229X, 2085R0001X, 2085R0203X, 208VP0000X, 208VP0014X
2085B0100X, 2085N0700X, 2085N0904X, 2085R0204X, 2085U0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083812Medicaid
CAGR0083812Medicaid