Provider Demographics
NPI:1760732150
Name:MD MEDICAL DIAGNOSTICS, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MD MEDICAL DIAGNOSTICS, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLOGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-493-4223
Mailing Address - Street 1:951 CALLE NEGOCIO
Mailing Address - Street 2:SUITE D
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6281
Mailing Address - Country:US
Mailing Address - Phone:949-493-4223
Mailing Address - Fax:949-493-8966
Practice Address - Street 1:30100 TOWN CENTER DR
Practice Address - Street 2:SUITE O-437
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2064
Practice Address - Country:US
Practice Address - Phone:949-493-4223
Practice Address - Fax:949-493-8966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty