Provider Demographics
NPI:1043390941
Name:MOBILE MEDICAL DIAGNOSTIC SERVICES OF OHIO
Entity Type:Organization
Organization Name:MOBILE MEDICAL DIAGNOSTIC SERVICES OF OHIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GALE
Authorized Official - Last Name:HOUSEWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-289-8085
Mailing Address - Street 1:821 SANDUSKY ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-1143
Mailing Address - Country:US
Mailing Address - Phone:419-289-8085
Mailing Address - Fax:419-289-8584
Practice Address - Street 1:821 SANDUSKY ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-1143
Practice Address - Country:US
Practice Address - Phone:419-289-8085
Practice Address - Fax:419-289-8584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2344887Medicaid
OH2344887Medicaid