Provider Demographics
NPI:1548385644
Name:DELTA RADIOLOGY, INC.
Entity Type:Organization
Organization Name:DELTA RADIOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-339-7560
Mailing Address - Street 1:975 S FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5118
Mailing Address - Country:US
Mailing Address - Phone:209-334-4416
Mailing Address - Fax:
Practice Address - Street 1:541 S HAM LN
Practice Address - Street 2:SUITE B
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3530
Practice Address - Country:US
Practice Address - Phone:209-333-7426
Practice Address - Fax:209-333-7865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0006152Medicaid
CAGR0006152Medicaid
CACP7019Medicare PIN