1417636093 NPI number — DIAGNOSTIC PATHOLOGY MEDICAL GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417636093 NPI number — DIAGNOSTIC PATHOLOGY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAGNOSTIC PATHOLOGY MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417636093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3301 C ST STE 200E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95816-3363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-447-6267
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARSON CITY
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89703-4625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-447-6267
Provider Business Practice Location Address Fax Number:
916-456-5872
Provider Enumeration Date:
07/12/2023

Additional Information

Authorized Official

Authorized Official Last Name:
BOADO
Authorized Official First Name:
JEANETTE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
916-447-6267

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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