Provider Demographics
NPI:1093798670
Name:OUTPATIENT DIAGNOSTIC CENTER OF DALLAS LP
Entity Type:Organization
Organization Name:OUTPATIENT DIAGNOSTIC CENTER OF DALLAS LP
Other - Org Name:TWO FOREST IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-955-4332
Mailing Address - Street 1:8610 EXPLORER DR
Mailing Address - Street 2:300
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1058
Mailing Address - Country:US
Mailing Address - Phone:719-955-4140
Mailing Address - Fax:719-955-4148
Practice Address - Street 1:12201 MERIT DR
Practice Address - Street 2:STE. 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2213
Practice Address - Country:US
Practice Address - Phone:214-276-0050
Practice Address - Fax:214-276-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162958601Medicaid
TXFTUVX1Medicare PIN