Provider Demographics
NPI:1417065103
Name:EASTERN SIERRA RADIOLOGY
Entity Type:Organization
Organization Name:EASTERN SIERRA RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLARD
Authorized Official - Last Name:NESSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-445-0004
Mailing Address - Street 1:333 N SANTA ANITA AVE
Mailing Address - Street 2:SUITE #9
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2863
Mailing Address - Country:US
Mailing Address - Phone:626-445-0004
Mailing Address - Fax:626-445-0302
Practice Address - Street 1:100 FALLS CANYON RD
Practice Address - Street 2:
Practice Address - City:AVALON
Practice Address - State:CA
Practice Address - Zip Code:90704-1563
Practice Address - Country:US
Practice Address - Phone:310-510-0700
Practice Address - Fax:626-445-0302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA221202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A221201Medicaid
CAZZZ04744ZOtherBLUE SHIELD
CAA22120OtherBLUE CROSS
CAA22120OtherBLUE CROSS
CA00A221201Medicaid