Basic Information
| Provider Information | |||||||||
| NPI: | 1407191356 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGH DESERT PATHOLOGY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10076 | ||||||||
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| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914100076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055783911 | ||||||||
| Practice Location | |||||||||
| Address1: | 16850 BEAR VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608436262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2012 | ||||||||
| LastUpdateDate: | 12/04/2012 | ||||||||
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| AuthorizedOfficialLastName: | TADROS | ||||||||
| AuthorizedOfficialFirstName: | REDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7608436262 | ||||||||
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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 | 207ZP0102X | 05D0563949 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 05D0562204 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 05D0643174 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.