Provider Demographics
NPI:1124342373
Name:INDEPENDENT DIAGNOSTIC TESTING INC
Entity type:Organization
Organization Name:INDEPENDENT DIAGNOSTIC TESTING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:E
Authorized Official - Last Name:SUFFICOOL
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:619-461-0039
Mailing Address - Street 1:7877 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2000
Mailing Address - Country:US
Mailing Address - Phone:619-461-0039
Mailing Address - Fax:619-461-5941
Practice Address - Street 1:7877 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2000
Practice Address - Country:US
Practice Address - Phone:619-461-0039
Practice Address - Fax:619-461-5941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335V00000X335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier