Healthcare Provider Details

I. General information

NPI: 1932342854
Provider Name (Legal Business Name): ALTA EAST BAY PATHOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 WEBSTER ST #1201
OAKLAND CA
94609-3117
US

IV. Provider business mailing address

1633 ERRINGER RD 1ST FLOOR
SIMI VALLEY CA
93065-3583
US

V. Phone/Fax

Practice location:
  • Phone: 805-578-8300
  • Fax: 805-578-3911
Mailing address:
  • Phone: 805-578-8300
  • Fax: 805-578-3911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number05D1082851
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number05D1082851
License Number StateCA

VIII. Authorized Official

Name: ANNETTE SHAIEB
Title or Position: PRESIDENT
Credential: MD
Phone: 805-578-8300