Provider Demographics
NPI:1295257822
Name:LA PUENTE MEDICAL DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:LA PUENTE MEDICAL DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMAD ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:DORAFSHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-999-0099
Mailing Address - Street 1:PO BOX 1147
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-8147
Mailing Address - Country:US
Mailing Address - Phone:714-995-5400
Mailing Address - Fax:714-995-5467
Practice Address - Street 1:569 S AZUSA WAY
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-5113
Practice Address - Country:US
Practice Address - Phone:626-861-4173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG436362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty