Provider Demographics
NPI:1346538428
Name:ICONIC DAGNOSTIC IMAGING INC
Entity Type:Organization
Organization Name:ICONIC DAGNOSTIC IMAGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-209-2544
Mailing Address - Street 1:10721 MAIN ST
Mailing Address - Street 2:#204
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6914
Mailing Address - Country:US
Mailing Address - Phone:703-209-2544
Mailing Address - Fax:
Practice Address - Street 1:10721 MAIN ST
Practice Address - Street 2:#204
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6914
Practice Address - Country:US
Practice Address - Phone:703-209-2544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty