Provider Demographics
NPI:1134283294
Name:MAMMOGRAPHY SPECIALISTS MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:MAMMOGRAPHY SPECIALISTS MEDICAL GROUP, INC
Other - Org Name:MAMMOGRAPHY SPECIALISTS MEDICAL GROUP, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DIPA
Authorized Official - Middle Name:H
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-800-5247
Mailing Address - Street 1:14651 S BASCOM AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2014
Mailing Address - Country:US
Mailing Address - Phone:408-356-6611
Mailing Address - Fax:408-356-9001
Practice Address - Street 1:14651 S BASCOM AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2014
Practice Address - Country:US
Practice Address - Phone:408-356-6611
Practice Address - Fax:408-356-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49899174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ24258ZMedicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
CA00G498990Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE
CA1699856187Medicare ID - Type UnspecifiedMEDICARE NPI FOR INDIVIDU