Basic Information
| Provider Information | |||||||||
| NPI: | 1235469685 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OC PATH MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | ORANGE REGIONAL PATHOLOGY ASSOCIATE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10076 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914100076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055783911 | ||||||||
| Practice Location | |||||||||
| Address1: | 3350 W BALL RD | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928043710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148276701 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2010 | ||||||||
| LastUpdateDate: | 05/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | LAKE | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7146330011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 05D0582538 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | 05D0582538 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.