Provider Demographics
NPI:1528308350
Name:MEDICAL IMAGING & THERAPEUTICS LLC
Entity type:Organization
Organization Name:MEDICAL IMAGING & THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-267-1963
Mailing Address - Street 1:922 SHORE ACRES DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-9269
Mailing Address - Country:US
Mailing Address - Phone:352-267-1963
Mailing Address - Fax:480-247-4206
Practice Address - Street 1:769 HIGHWAY 466
Practice Address - Street 2:SUITE 769
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-6340
Practice Address - Country:US
Practice Address - Phone:352-261-5502
Practice Address - Fax:480-247-4206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty