Provider Demographics
NPI:1790725141
Name:SAN GABRIEL VALLEY DIAGNOSTIC CENTER MEDICAL GROUP
Entity Type:Organization
Organization Name:SAN GABRIEL VALLEY DIAGNOSTIC CENTER MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BHARATH
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:KRISHNASAMY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-962-3525
Mailing Address - Street 1:1509 W CAMERON AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2725
Mailing Address - Country:US
Mailing Address - Phone:626-962-3525
Mailing Address - Fax:626-962-0032
Practice Address - Street 1:1509 W CAMERON AVE
Practice Address - Street 2:SUITE D
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2725
Practice Address - Country:US
Practice Address - Phone:626-962-3525
Practice Address - Fax:626-962-0032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ11986ZOtherBLUE SHIELD OF CALIF
CAGR0023300Medicaid
CAZZZ11986ZOtherBLUE SHIELD OF CALIF