Basic Information
Provider Information | |||||||||
NPI: | 1346703642 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DIAGNOSTIC PATHOLOGY MEDICAL GROUP, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3301 C ST STE 200E | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958163363 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9164476267 | ||||||||
FaxNumber: | 9164565842 | ||||||||
Practice Location | |||||||||
Address1: | 1680 E ROSEVILLE PKWY # 100 | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956613988 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9164476267 | ||||||||
FaxNumber: | 9164565842 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2019 | ||||||||
LastUpdateDate: | 04/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOADO | ||||||||
AuthorizedOfficialFirstName: | JEANETTE | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 9164476267 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology |
No ID Information.