1477582161 NPI number — CALIFORNIA PATHOLOGY MEDICAL GROUP

Table of content: (NPI 1477582161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477582161 NPI number — CALIFORNIA PATHOLOGY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALIFORNIA PATHOLOGY MEDICAL GROUP
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:
1477582161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3116 W MARCH LN STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95219-2370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-473-6555
Provider Business Mailing Address Fax Number:
209-473-6544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5555 W LAS POSITAS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLEASANTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94588-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-473-6555
Provider Business Practice Location Address Fax Number:
209-473-6544
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ENFIELD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
209-473-6555

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0090470 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00116598 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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