Provider Demographics
NPI:1649575671
Name:INTERMED IMAGING A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:INTERMED IMAGING A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:PRESTON
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-671-9754
Mailing Address - Street 1:125 N PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1904
Mailing Address - Country:US
Mailing Address - Phone:310-671-9754
Mailing Address - Fax:310-671-3916
Practice Address - Street 1:880 E TUOLUMNE RD
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-1548
Practice Address - Country:US
Practice Address - Phone:310-671-9754
Practice Address - Fax:310-671-3916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC339352085B0100X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0202X, 2085R0203X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Single Specialty
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC33935OtherMEDICAL LICENSE
CA00C339353OtherMEDICARE NO CA
CA00C339350OtherMEDICAID NO CA
CA00C339350OtherMEDICAID NO CA
CAAM1521815OtherDEA