Provider Demographics
NPI:1396737474
Name:CALIFORNIA DIAGNOSTIC IMAGING CENTER A MEDICAL CORPORATION
Entity type:Organization
Organization Name:CALIFORNIA DIAGNOSTIC IMAGING CENTER A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-339-5464
Mailing Address - Street 1:BOX 5010
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-0735
Mailing Address - Country:US
Mailing Address - Phone:626-915-5181
Mailing Address - Fax:626-331-2313
Practice Address - Street 1:828 S GRAND AVE
Practice Address - Street 2:STE 104
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4856
Practice Address - Country:US
Practice Address - Phone:626-915-5181
Practice Address - Fax:626-331-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0103720Medicaid
CAP00081546OtherRAIL ROAD MEDICARE GRP #
CAZZZ07258ZOtherBLUE SHIELD
CAGR0103720Medicaid