Basic Information
| Provider Information | |||||||||
| NPI: | 1174043202 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JUPITER IMAGING ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3147 | ||||||||
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| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548382371 | ||||||||
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| Practice Location | |||||||||
| Address1: | 725 RANTOUL LN | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327464249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548382371 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2017 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | DROZDOW | ||||||||
| AuthorizedOfficialFirstName: | GILBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9548382371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.