Basic Information
| Provider Information | |||||||||
| NPI: | 1770544819 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLACENTIA 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1301 N ROSE DR | ||||||||
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| City: | PLACENTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928703802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145244842 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ANDORKA | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7145244842 | ||||||||
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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 | 207ZC0500X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | GR0064590 | 05 | CA | MEDICAID |