Active NPI
Medical Diagnostic Laboratories
- Clinical Pathology/Laboratory Medicine Physician
- Stockton, CA
National Provider Identifier
1154436897
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Pathology/Laboratory Medicine Physician
- License
- G54073
- Legal business name
- MEDICAL DIAGNOSTIC LABORATORIES
- Practice address
- 3116 W March LN Ste 200
Stockton, CA 95219-2370 - Phone
- (209) 473-6555
- Fax
- (209) 473-6544
- NPI assigned
- Aug 21, 2006
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- David Jensen, MD
- Title
- Sole Proprietor
- Phone
- (209) 473-6555
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Pathology/Laboratory Medicine Physician | 207ZP0105X | G54073 | CA | Primary |
Addresses
Primary practice location
3116 W March LN Ste 200
Stockton, CA 95219-2370
Mailing address
3116 W March LN Ste 200
Stockton, CA 95219-2370
Phone (209) 473-6555
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00G540730 | Medicaid | CA | |
| G54073 | Other | CA | CA LICENSE # |
National Provider Directory
National Provider Directory- Tax ID family
- Medical Diagnostic Laboratories
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
-
- Anatomic Pathology & Clinical Pathology Physician
- Morgan Hill, CA
- NPI 1700273315
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156118400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1598054400000",
"number": "1154436897",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3116 W MARCH LN STE 200",
"city": "STOCKTON",
"state": "CA",
"postal_code": "952192370",
"telephone_number": "209-473-6555",
"fax_number": "209-473-6544"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3116 W MARCH LN STE 200",
"city": "STOCKTON",
"state": "CA",
"postal_code": "952192370",
"telephone_number": "209-473-6555",
"fax_number": "209-473-6544"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "MEDICAL DIAGNOSTIC LABORATORIES",
"organizational_subpart": "NO",
"enumeration_date": "2006-08-21",
"last_updated": "2020-08-22",
"status": "A",
"authorized_official_last_name": "JENSEN",
"authorized_official_first_name": "DAVID",
"authorized_official_title_or_position": "SOLE PROPRIETOR",
"authorized_official_telephone_number": "209-473-6555",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "207ZP0105X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Pathology, Clinical Pathology/Laboratory Medicine",
"state": "CA",
"license": "G54073",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "00G540730",
"state": "CA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CA LICENSE #",
"identifier": "G54073",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Stockton, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.