Provider Demographics
NPI:1023045374
Name:COMPLETE MOBILE DIAGNOSTICS, PA
Entity Type:Organization
Organization Name:COMPLETE MOBILE DIAGNOSTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDIC
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-475-6683
Mailing Address - Street 1:4302 RUNNING BROOK DR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-9256
Mailing Address - Country:US
Mailing Address - Phone:972-475-6683
Mailing Address - Fax:
Practice Address - Street 1:4302 RUNNING BROOK DR
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-9256
Practice Address - Country:US
Practice Address - Phone:972-475-6683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1837437-01Medicaid
TX00W774Medicare PIN