Provider Demographics
NPI:1629109111
Name:RADIOLOGY ASSOCIATES OF DURANGO PC
Entity Type:Organization
Organization Name:RADIOLOGY ASSOCIATES OF DURANGO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-259-2525
Mailing Address - Street 1:PO BOX 394
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-0394
Mailing Address - Country:US
Mailing Address - Phone:877-406-2976
Mailing Address - Fax:719-591-2745
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-764-2286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME2677Medicaid
TXX9X000484Medicaid
209463OtherUS DEPARTMENT OF LABOR
CO04005427Medicaid
AZ825698Medicaid
CA10025313600Medicaid
CORAB6508OtherBLUE CROSS BLUE SHIELD
NME2677Medicaid
209463OtherUS DEPARTMENT OF LABOR
209463OtherUS DEPARTMENT OF LABOR
COCI1410Medicare ID - Type Unspecified