Healthcare Provider Details

I. General information

NPI: 1154436897
Provider Name (Legal Business Name): MEDICAL DIAGNOSTIC LABORATORIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 W MARCH LN STE 200
STOCKTON CA
95219-2370
US

IV. Provider business mailing address

3116 W MARCH LN STE 200
STOCKTON CA
95219-2370
US

V. Phone/Fax

Practice location:
  • Phone: 209-473-6555
  • Fax: 209-473-6544
Mailing address:
  • Phone: 209-473-6555
  • Fax: 209-473-6544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberG54073
License Number StateCA

VIII. Authorized Official

Name: DAVID JENSEN
Title or Position: SOLE PROPRIETOR
Credential: MD
Phone: 209-473-6555