Provider Demographics
NPI:1023230752
Name:PACIFIC RADIOLOGY INC A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PACIFIC RADIOLOGY INC A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:V
Authorized Official - Last Name:LIZAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:671-777-5259
Mailing Address - Street 1:121 TAKANO LN STE 302
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-4148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:388 YPAO RD
Practice Address - Street 2:SDA RADIOLOGY DEPARTMENT
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3701
Practice Address - Country:US
Practice Address - Phone:671-646-8881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUH56719Medicare ID - Type Unspecified