Provider Demographics
NPI:1851621288
Name:WILLOWBEND DIAGNOSTIC IMAGING, PLLC
Entity Type:Organization
Organization Name:WILLOWBEND DIAGNOSTIC IMAGING, PLLC
Other - Org Name:INSIGHT IMAGING - WILLOWBEND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:FULMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-596-1934
Mailing Address - Street 1:26250 ENTERPRISE COURT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630
Mailing Address - Country:US
Mailing Address - Phone:949-282-6026
Mailing Address - Fax:
Practice Address - Street 1:5025 W PARK BLVD
Practice Address - Street 2:BLDG A, SUITE 500
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-2584
Practice Address - Country:US
Practice Address - Phone:972-596-1934
Practice Address - Fax:972-596-4934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2012-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty