Provider Demographics
NPI:1568489433
Name:OLD COUNTRY ROAD IMAGING AND DIAGNOSTICS
Entity Type:Organization
Organization Name:OLD COUNTRY ROAD IMAGING AND DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEMARCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-507-4700
Mailing Address - Street 1:184 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4200
Mailing Address - Country:US
Mailing Address - Phone:516-739-2464
Mailing Address - Fax:
Practice Address - Street 1:184 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4200
Practice Address - Country:US
Practice Address - Phone:516-739-2464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty