Basic Information
| Provider Information | |||||||||
| NPI: | 1649386913 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSION PATHOLOGY MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27700 MEDICAL CENTER RD | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493641400 | ||||||||
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| Address1: | 27700 MEDICAL CENTER RD | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493641400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 03/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | EKUAN | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9493641400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 05D0903813 | CA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | GR0014030 | 05 | CA | MEDICAID |