Organization
RIO GRANDE DIAGNOSTIC IMAGING, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. IRA SAM KUPETZ MD (PRESIDENT)
(817) 731-7771
Entity
Organization
Contact information
Practice address
1801 N OREGON ST, EL PASO, TX 79902-3524
(915) 595-9202
(915) 595-9781
Mailing address
PO BOX 101957, FORT WORTH, TX 76185-1957
(817) 731-7771
(817) 731-7774
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0003EE
BCBS
TX
05
—
00077304
—
TX
05
—
095053701
—
TX
05
—
201074651
—
TX
01
—
CG5428
MEDICARE RR
TX
Enumeration date
11/16/2006
Last updated
04/22/2008
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