Provider Demographics
NPI:1598262669
Name:QUUENS DIAGNOSTIC RADIOLOGY, PC
Entity Type:Organization
Organization Name:QUUENS DIAGNOSTIC RADIOLOGY, PC
Other - Org Name:QUUENS DIAGNOSTIC RADIOLOGY, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LODESPOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-764-2222
Mailing Address - Street 1:25302 ROCKAWAY BLVD # B
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3114
Mailing Address - Country:US
Mailing Address - Phone:718-764-2222
Mailing Address - Fax:516-666-8655
Practice Address - Street 1:25302 ROCKAWAY BLVD # B
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3114
Practice Address - Country:US
Practice Address - Phone:718-764-2222
Practice Address - Fax:516-666-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1710632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY171063OtherLICENSE
NY95B751OtherMEDICARE INDIVIDUAL