Provider Demographics
NPI:1114478849
Name:MD NEURODIAGNOSTIC MGT SVCS
Entity Type:Organization
Organization Name:MD NEURODIAGNOSTIC MGT SVCS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-600-1572
Mailing Address - Street 1:PO BOX 941715
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93094-1715
Mailing Address - Country:US
Mailing Address - Phone:818-600-1572
Mailing Address - Fax:877-705-3046
Practice Address - Street 1:2655 1ST ST STE 250
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1574
Practice Address - Country:US
Practice Address - Phone:818-600-1572
Practice Address - Fax:877-705-3046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA1299532084N0400X
FLME942182084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30990ZOther30990Z
FL30990ZOther30990Z