Healthcare Provider Details

I. General information

NPI: 1285699793
Provider Name (Legal Business Name): PENINSULA PATHOLOGISTS MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1783 EL CAMINO REAL PATHOLOGY DEPT
BURLINGAME CA
94010-3205
US

IV. Provider business mailing address

383 E GRAND AVE SUITE A
SOUTH SAN FRANCISCO CA
94080-6234
US

V. Phone/Fax

Practice location:
  • Phone: 650-696-5611
  • Fax:
Mailing address:
  • Phone: 650-616-2951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberCLF331997
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberCLF331997
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberCLF331997
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUDY A ALONZO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 650-616-2950