Provider Demographics
NPI:1598838617
Name:MEDICAL DIAGNOSTIC ASSOCIATES, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MEDICAL DIAGNOSTIC ASSOCIATES, A MEDICAL CORPORATION
Other - Org Name:MDIA, A MEDICAL CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-400-4674
Mailing Address - Street 1:20750 VENTURA BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-6647
Mailing Address - Country:US
Mailing Address - Phone:800-400-4674
Mailing Address - Fax:818-251-1112
Practice Address - Street 1:5706 CORSA AVE STE 200-O
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-4057
Practice Address - Country:US
Practice Address - Phone:800-400-4674
Practice Address - Fax:818-251-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty