Provider Demographics
NPI:1700979390
Name:WESTERN DIAGNOSTIC & THERAPEUTIC RADIOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:WESTERN DIAGNOSTIC & THERAPEUTIC RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:WESTERN RADIOLOGIC MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:N
Authorized Official - Last Name:LOIZEAUX-WITTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-836-1574
Mailing Address - Street 1:4640 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6621
Mailing Address - Country:US
Mailing Address - Phone:310-836-1574
Mailing Address - Fax:310-836-6925
Practice Address - Street 1:4640 ADMIRALTY WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6621
Practice Address - Country:US
Practice Address - Phone:310-836-1574
Practice Address - Fax:310-836-6925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0017071Medicaid
CAGR0017076Medicaid
CAGR0017072Medicaid
CAW10112AMedicare PIN
CAGR0017072Medicaid
CAW13956Medicare PIN