Provider Demographics
NPI:1336161918
Name:DIAGNOSTIC IMAGING ASSOCIATES LLC
Entity type:Organization
Organization Name:DIAGNOSTIC IMAGING ASSOCIATES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
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 SOUTH
Mailing Address - Street 2:C/O NVRA UNION SQUARE BUILDING #1
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488
Mailing Address - Country:US
Mailing Address - Phone:203-264-7999
Mailing Address - Fax:203-264-7477
Practice Address - Street 1:1389 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-574-1311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004068623Medicaid
CT004068623Medicaid