Provider Demographics
NPI:1992797070
Name:GLENDORA RADIOLOGICAL ASSOC INC
Entity type:Organization
Organization Name:GLENDORA RADIOLOGICAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-339-5464
Mailing Address - Street 1:414 E SAN BERNARDINO RD
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1704
Mailing Address - Country:US
Mailing Address - Phone:800-475-3698
Mailing Address - Fax:626-331-2313
Practice Address - Street 1:414 E SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1704
Practice Address - Country:US
Practice Address - Phone:626-339-5464
Practice Address - Fax:626-331-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP3326OtherRAIL ROAD MEDICARE GRP #
CAZZZ35484ZOtherBLUE SHIELD PROVIDER
CAZZZ14525ZOtherBLUE SHIELD PROVIDER
CAGR0011500Medicaid
CAGR0011502Medicaid
CAHW351Medicare PIN
CAGR0011500Medicaid