Provider Demographics
NPI:1417089962
Name:DIAGNOSTIC IMAGING MEDICAL GROUP
Entity Type:Organization
Organization Name:DIAGNOSTIC IMAGING MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SONNABEND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-739-3412
Mailing Address - Street 1:PO BOX 17886
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-1033
Mailing Address - Country:US
Mailing Address - Phone:805-434-4989
Mailing Address - Fax:
Practice Address - Street 1:1400 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5906
Practice Address - Country:US
Practice Address - Phone:805-739-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-11
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18870ZOtherBLUE SHIELD
CAGR0011720Medicaid
CAGR0011721Medicaid
CA1417089962Medicaid