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General NPI Number Information
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NPI Number | 1215283619
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Entity Type | Organization
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Legal Business Name | ORANGE REGIONAL PATHOLOGY ASSOCIATES
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Dates
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Enumeration Date | 08/03/2012
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Last Update Date | 08/03/2012
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Provider Practice Location Address
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Address Line | 2231 S WESTERN AVE
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City | LOS ANGELES
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State | CA
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Zip | 90018-1302
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Country | US
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Telephone | 323-730-7371
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 10076
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City | VAN NUYS
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State | CA
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Zip | 91410-0076
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Country | US
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Telephone | 805-578-8300
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Fax | 805-578-3911
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Authorized Official
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Title or Position | PRESIDENT
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Name | JON P LAKE
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Credential | MD
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Telephone | 323-730-7371
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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 | 05D0058772
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License Number State | CA
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