Provider Demographics
NPI:1255844106
Name:COMPREHENSIVE DIAGNOSTIC IMAGING OF WISCONSIN, LLC
Entity Type:Organization
Organization Name:COMPREHENSIVE DIAGNOSTIC IMAGING OF WISCONSIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZULLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-281-2100
Mailing Address - Street 1:2500 W LAYTON AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5400
Mailing Address - Country:US
Mailing Address - Phone:262-261-9423
Mailing Address - Fax:414-539-4185
Practice Address - Street 1:2500 W LAYTON AVE STE 20
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5400
Practice Address - Country:US
Practice Address - Phone:262-261-9423
Practice Address - Fax:414-539-4185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MammographyGroup - Single Specialty