Basic Information
Provider Information | |||||||||
NPI: | 1609948983 | ||||||||
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 | ||||||||
Address2: | SUITE #200-E | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958163300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9164476267 | ||||||||
FaxNumber: | 9164470621 | ||||||||
Practice Location | |||||||||
Address1: | 11815 EDUCATION ST | ||||||||
Address2: |   | ||||||||
City: | AUBURN | ||||||||
State: | CA | ||||||||
PostalCode: | 956022410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9164476267 | ||||||||
FaxNumber: | 9164470621 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2006 | ||||||||
LastUpdateDate: | 03/05/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUTLER | ||||||||
AuthorizedOfficialFirstName: | DONALD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9164460424 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | CS7233 | 01 | CA | MEDICARE RAILROAD | OTHER | ZZZ39657Z | 01 | CA | MEDICARE PTAN | OTHER | GR0010577 | 05 | CA |   | MEDICAID |