Provider Demographics
NPI:1285870089
Name:DIAGNOSTIC IMAGING PA
Entity type:Organization
Organization Name:DIAGNOSTIC IMAGING PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAHID
Authorized Official - Middle Name:M
Authorized Official - Last Name:NASIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-629-6733
Mailing Address - Street 1:130 CORRIDOR RD UNIT 428
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32004-7718
Mailing Address - Country:US
Mailing Address - Phone:904-551-0703
Mailing Address - Fax:904-551-0709
Practice Address - Street 1:1052 PONTE VEDRA BLVD
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4015
Practice Address - Country:US
Practice Address - Phone:904-551-0703
Practice Address - Fax:904-551-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-29
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000703600Medicaid
FL000703600Medicaid