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General NPI Number Information
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NPI Number | 1093742074
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Entity Type | Organization
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Legal Business Name | LABORATORY DIAGNOSTICS MEDICAL GROUP
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Dates
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Enumeration Date | 06/27/2006
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Last Update Date | 01/11/2016
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Provider Practice Location Address
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Address Line | 9888 GENESEE AVE
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City | LA JOLLA
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State | CA
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Zip | 92037-1276
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Country | US
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Telephone | 858-626-6000
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Fax | 419-866-5453
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Provider Business Mailing Address
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Address Line | 1801 W OLYMPIC BLVD #1016
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City | PASADENA
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State | CA
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Zip | 91199-0001
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Country | US
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Telephone | 800-288-8325
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Fax | 419-866-5453
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Authorized Official
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Title or Position | PRESIDENT
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Name | STEPHEN CARLSON
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Credential | MD
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Telephone | 858-626-6000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 05D0663110
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License Number State | CA
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