Provider Demographics
NPI:1225105729
Name:GOLDEN WEST RADIOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:GOLDEN WEST RADIOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-375-8823
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91319-9070
Mailing Address - Country:US
Mailing Address - Phone:800-318-6347
Mailing Address - Fax:805-375-8903
Practice Address - Street 1:1111 WEST LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2804
Practice Address - Country:US
Practice Address - Phone:714-999-6080
Practice Address - Fax:714-999-3924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT40226FOtherMCAL OP FACILITY ID
CAZZZ77487ZMedicaid
CAHSC30226FOtherMCAL IP FACILITY ID
HW1388Medicare ID - Type Unspecified