Provider Demographics
NPI:1982653598
Name:PACIFIC NETWORK IMAGING, INC.
Entity Type:Organization
Organization Name:PACIFIC NETWORK IMAGING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:WATTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-218-5758
Mailing Address - Street 1:101 S SAN MATEO DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3819
Mailing Address - Country:US
Mailing Address - Phone:650-217-8575
Mailing Address - Fax:650-375-8398
Practice Address - Street 1:101 S SAN MATEO DR
Practice Address - Street 2:SUITE 303
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3819
Practice Address - Country:US
Practice Address - Phone:650-217-8575
Practice Address - Fax:650-375-8398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ23000ZMedicare ID - Type Unspecified