Basic Information
Provider Information | |||||||||
NPI: | 1205898475 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DESERT PATHOLOGY MEDICAL GROUP, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14275 MIDWAY ROAD | ||||||||
Address2: | SUITE 400 | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750013676 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2149328029 | ||||||||
FaxNumber: | 6102714245 | ||||||||
Practice Location | |||||||||
Address1: | 1150 N INDIAN CANYON DR | ||||||||
Address2: | DESERT REGIONAL MED CTR PATHOLOGY DEPT | ||||||||
City: | PALM SPRINGS | ||||||||
State: | CA | ||||||||
PostalCode: | 922624872 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7603236198 | ||||||||
FaxNumber: | 7603236195 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2006 | ||||||||
LastUpdateDate: | 04/11/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHERMAN | ||||||||
AuthorizedOfficialFirstName: | NATHAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
AuthorizedOfficialTelephone: | 7038026900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
ID | Type | State | Issuer | Description | GR0058480 | 05 | CA |   | MEDICAID |