Provider Demographics
NPI:1912282781
Name:INDEPENDENT DIAGNOSTIC TESTS INC
Entity Type:Organization
Organization Name:INDEPENDENT DIAGNOSTIC TESTS INC
Other - Org Name:IDT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
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:
Authorized Official - Phone:619-971-3004
Mailing Address - Street 1:8216 STARLAND DR
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-1877
Mailing Address - Country:US
Mailing Address - Phone:619-971-3004
Mailing Address - Fax:855-473-0120
Practice Address - Street 1:8216 STARLAND DR
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-1877
Practice Address - Country:US
Practice Address - Phone:619-971-3004
Practice Address - Fax:855-473-0120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW0036Medicare UPIN