Provider Demographics
NPI:1467722918
Name:OLYMPUS RADIOLOGY MEDICAL GROUP, INC., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:OLYMPUS RADIOLOGY MEDICAL GROUP, INC., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBEN
Authorized Official - Middle Name:DAN
Authorized Official - Last Name:AHDOOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-458-7742
Mailing Address - Street 1:2835 MORAGA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1614
Mailing Address - Country:US
Mailing Address - Phone:818-458-7742
Mailing Address - Fax:
Practice Address - Street 1:3828 DELMAS TER
Practice Address - Street 2:DEPT. OF RADIOLOGY
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2713
Practice Address - Country:US
Practice Address - Phone:310-836-7001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty