Provider Demographics
NPI:1073565115
Name:DIAGNOSTIC RADIOLOGY
Entity Type:Organization
Organization Name:DIAGNOSTIC RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-348-1900
Mailing Address - Street 1:PO BOX 2080
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-2080
Mailing Address - Country:US
Mailing Address - Phone:405-348-1900
Mailing Address - Fax:405-348-0423
Practice Address - Street 1:902 S BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5742
Practice Address - Country:US
Practice Address - Phone:405-348-1900
Practice Address - Fax:405-348-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100734560AMedicaid
OK100734560AMedicaid
OK=========001OtherBLUE CROSS BLUE SHIELD