Provider Demographics
NPI:1285899021
Name:KODIAK DIAGNOSTIC IMAGING, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:KODIAK DIAGNOSTIC IMAGING, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:E
Authorized Official - Last Name:RIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-486-2466
Mailing Address - Street 1:384 LILLY DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-7115
Mailing Address - Country:US
Mailing Address - Phone:907-486-2466
Mailing Address - Fax:
Practice Address - Street 1:1915 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6602
Practice Address - Country:US
Practice Address - Phone:907-539-8997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK49242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty