Provider Demographics
NPI:1356305767
Name:FLORIDA DIAGNOSTIC IMAGING INC
Entity Type:Organization
Organization Name:FLORIDA DIAGNOSTIC IMAGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-676-5323
Mailing Address - Street 1:5201 BABCOCK ST NE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4637
Mailing Address - Country:US
Mailing Address - Phone:321-676-5323
Mailing Address - Fax:321-951-9253
Practice Address - Street 1:5201 BABCOCK ST NE
Practice Address - Street 2:SUITE 5
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4637
Practice Address - Country:US
Practice Address - Phone:321-676-5323
Practice Address - Fax:321-951-9253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5282261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102370OtherAVMED
FL40016OtherFLORIDIANCARE
FLFDA 155978OtherEMBRACED PROGRAM
FLV2489OtherBCBS OF FLORIDA
FL1209448OtherFIRST HEALTH/MAIL HANDLER
FL16-00554OtherUNITEDHEALTHCARE MEDIPASS
FL17030OtherSTAYWELL/WELLCARE
FL288660OtherAMERIGROUP
FL1488395OtherUNITED HEALTHCARE
FL17030OtherHEALTHEASE
FLOS0004065OtherWORKERS COMPENSATION
FL0782103OtherCIGNA
FL8208068OtherAETNA
FL16-00554OtherUNITEDHEALTHCARE MEDIPASS
FL8208068OtherAETNA