Healthcare Provider Details

I. General information

NPI: 1356735989
Provider Name (Legal Business Name): SPECIALIZED UNIVERSITY PATHOLOGISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 TECHNOLOGY DR STE 100C
IRVINE CA
92618-2484
US

IV. Provider business mailing address

PO BOX 745227
LOS ANGELES CA
90074-5227
US

V. Phone/Fax

Practice location:
  • Phone: 424-302-3307
  • Fax: 818-279-6939
Mailing address:
  • Phone: 424-302-3307
  • Fax: 818-279-6939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG81612
License Number StateCA

VIII. Authorized Official

Name: DR. KIARASH MICHEL
Title or Position: MD/OWNER
Credential: MD
Phone: 424-245-7284