Organization
SAN GABRIEL VALLEY DIAGNOSTIC CENTER MEDICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BHARATH KUMAR KRISHNASAMY M.D. (MEDICAL DIRECTOR)
(626) 962-3525
Entity
Organization
Contact information
Practice address
1509 W CAMERON AVE, SUITE D, WEST COVINA, CA 91790-2725
(626) 962-3525
(626) 962-0032
Mailing address
1509 W CAMERON AVE, SUITE D, WEST COVINA, CA 91790-2725
(626) 962-3525
(626) 962-0032
Taxonomy
Speciality
Code
Description
License number
State
2085N0904X
Nuclear Radiology Physician
—
—
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0023300
—
CA
01
—
ZZZ11986Z
BLUE SHIELD OF CALIF
CA
Enumeration date
06/07/2006
Last updated
05/25/2011
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