Provider Demographics
NPI:1457307803
Name:MDC RADIOLOGY, INC.
Entity Type:Organization
Organization Name:MDC RADIOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEIMANTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDRYTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-545-7177
Mailing Address - Street 1:373 W PALMER AVE
Mailing Address - Street 2:UNIT C
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2290
Mailing Address - Country:US
Mailing Address - Phone:818-545-7177
Mailing Address - Fax:818-545-7126
Practice Address - Street 1:373 W PALMER AVE
Practice Address - Street 2:UNIT C
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2290
Practice Address - Country:US
Practice Address - Phone:818-545-7177
Practice Address - Fax:818-545-7126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28728352471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN/AMedicare ID - Type UnspecifiedIDTF