Provider Demographics
NPI:1629187695
Name:PET IMAGING OF SAN JOSE, LLC
Entity Type:Organization
Organization Name:PET IMAGING OF SAN JOSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BIJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARHANGUI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-297-8844
Mailing Address - Street 1:2211 MOORPARK AVE.
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2632
Mailing Address - Country:US
Mailing Address - Phone:408-297-8844
Mailing Address - Fax:408-297-8220
Practice Address - Street 1:2211 MOORPARK AVE.
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2632
Practice Address - Country:US
Practice Address - Phone:408-297-8844
Practice Address - Fax:408-297-8220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6846-43174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ19866ZMedicare ID - Type UnspecifiedMEDICARE GROUP #