Provider Demographics
NPI:1982875217
Name:MEDICAL DIAGNOSTIC CENTER OF JACKSONVILLE
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTIC CENTER OF JACKSONVILLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KEESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:COMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-731-1556
Mailing Address - Street 1:PO BOX 5606
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-5606
Mailing Address - Country:US
Mailing Address - Phone:904-446-9093
Mailing Address - Fax:904-446-9095
Practice Address - Street 1:3716 UNIVERSITY BLVD S STE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4318
Practice Address - Country:US
Practice Address - Phone:904-446-9093
Practice Address - Fax:904-446-9095
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL DIAGNOSTIC CENTER OF JACKSONVILLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-14
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology