Basic Information
| Provider Information | |||||||||
| NPI: | 1093742074 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LABORATORY DIAGNOSTICS MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 W OLYMPIC BLVD | ||||||||
| Address2: | #1016 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911990001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 9888 GENESEE AVE | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586266000 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 01/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | CARLSON | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8586266000 | ||||||||
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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 | 207ZP0102X | 05D0663110 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | GR00086691 | 05 | CA | MEDICAID |