Organization
DIGITAL & RADIOLOGIC IMAGING ASSOCIATES INC. A MEDICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELLIOTT J. WAGNER M.D. (PRESIDENT)
(949) 348-1105
Entity
Organization
Contact information
Practice address
17100 EUCLID ST, FOUNTAIN VALLEY, CA 92708-4004
(714) 966-8041
Mailing address
PO BOX 3148, MISSION VIEJO, CA 92690-1148
(949) 348-1105
(949) 348-1210
Taxonomy
Speciality
Code
Description
License number
State
207U00000X
Nuclear Medicine Physician
—
—
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
2085R0204X
Vascular & Interventional Radiology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0019852
—
CA
01
—
ZZZ36724Z
BLUE SHIELD
CA
Enumeration date
05/16/2006
Last updated
02/27/2008
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