Healthcare Provider Details

I. General information

NPI: 1023673167
Provider Name (Legal Business Name): DIAGNOSTIC PATHOLOGY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 S FAIRMONT AVE
LODI CA
95240-5118
US

IV. Provider business mailing address

3301 C ST STE 200E
SACRAMENTO CA
95816-3363
US

V. Phone/Fax

Practice location:
  • Phone: 916-447-6267
  • Fax: 916-456-5842
Mailing address:
  • Phone: 916-447-6267
  • Fax: 916-456-5842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DEREK K MARSEE
Title or Position: PRESIDENT
Credential: MD
Phone: 916-447-6267