Basic Information
| Provider Information | |||||||||
| NPI: | 1770064271 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC PATHOLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 C ST | ||||||||
| Address2: | SUITE 200E | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958163300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164476267 | ||||||||
| FaxNumber: | 9164565842 | ||||||||
| Practice Location | |||||||||
| Address1: | 6490 S MCCARRAN BLVD | ||||||||
| Address2: | BLDGE E STE 106 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164476267 | ||||||||
| FaxNumber: | 9164565842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2018 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | MARSEE | ||||||||
| AuthorizedOfficialFirstName: | DEREK | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9164476267 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD.,PH.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.