Provider Demographics
NPI:1154304640
Name:KON, DARISSA S (MD)
Entity Type:Individual
Prefix:
First Name:DARISSA
Middle Name:S
Last Name:KON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4241 LONG BEACH BLVD
Mailing Address - Street 2:RAD-IMAGE MEDICAL GROUP INC.
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2003
Mailing Address - Country:US
Mailing Address - Phone:562-912-2507
Mailing Address - Fax:484-918-2507
Practice Address - Street 1:4241 LONG BEACH BLVD
Practice Address - Street 2:RAD-IMAGE MEDICAL GROUP INC.
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2003
Practice Address - Country:US
Practice Address - Phone:562-912-2507
Practice Address - Fax:484-918-2507
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA711652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H41871Medicare UPIN