Provider Demographics
NPI:1497894620
Name:CARDIOVASCULAR DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:CARDIOVASCULAR DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-338-3540
Mailing Address - Street 1:402 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5326
Mailing Address - Country:US
Mailing Address - Phone:318-338-3540
Mailing Address - Fax:318-335-3542
Practice Address - Street 1:402 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5326
Practice Address - Country:US
Practice Address - Phone:318-338-3540
Practice Address - Fax:318-335-3542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2012-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11314R207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1667781Medicaid
G19986Medicare UPIN
LA5W448Medicare PIN