Provider Demographics
NPI:1558459438
Name:DESERT VALLEY RADIOLOGY, PLC
Entity Type:Organization
Organization Name:DESERT VALLEY RADIOLOGY, PLC
Other - Org Name:DESERT VALLEY RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALL III
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-867-0404
Mailing Address - Street 1:4045 E. BELL RD.
Mailing Address - Street 2:STE. 143
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2245
Mailing Address - Country:US
Mailing Address - Phone:602-867-0404
Mailing Address - Fax:602-788-0893
Practice Address - Street 1:8380 S. KYRENE
Practice Address - Street 2:STE. 105
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-2120
Practice Address - Country:US
Practice Address - Phone:480-785-2511
Practice Address - Fax:480-705-4431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ333218Medicaid
AZ68255Medicare ID - Type Unspecified
AZ333218Medicaid