Provider Demographics
NPI:1891747200
Name:DIGITAL & RADIOLOGIC IMAGING ASSOCIATES INC. A MEDICAL GROUP
Entity Type:Organization
Organization Name:DIGITAL & RADIOLOGIC IMAGING ASSOCIATES INC. A MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-348-1105
Mailing Address - Street 1:PO BOX 3148
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92690-1148
Mailing Address - Country:US
Mailing Address - Phone:949-348-1105
Mailing Address - Fax:949-348-1210
Practice Address - Street 1:17100 EUCLID ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4004
Practice Address - Country:US
Practice Address - Phone:714-966-8041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ36724ZOtherBLUE SHIELD
CAGR0019852Medicaid
CAGR0019852Medicaid
CAW8723AMedicare PIN