Basic Information
| Provider Information | |||||||||
| NPI: | 1922384122 | ||||||||
| 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: | 3714 NORTHGATE BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958341617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164476267 | ||||||||
| FaxNumber: | 9164565842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2011 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9164476267 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 05D2001809 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.