Provider Demographics
NPI:1538399555
Name:SAN FERNANDO DIAGNOSTIC AND IMAGING, INC
Entity type:Organization
Organization Name:SAN FERNANDO DIAGNOSTIC AND IMAGING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-361-5269
Mailing Address - Street 1:16060 VENTURA BLVD STE 105-338
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2761
Mailing Address - Country:US
Mailing Address - Phone:818-361-5269
Mailing Address - Fax:818-837-7291
Practice Address - Street 1:211 S MACLAY AVE
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-3603
Practice Address - Country:US
Practice Address - Phone:818-408-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty