NPIMap

Organization Active NPI

Mitomed Diagnostics Laboratory

  • Clinical Medical Laboratory
  • Irvine, CA
National Provider Identifier
1356595011
Registry record updated Nov 7, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Medical LaboratoryTaxonomy code 291U00000X
License
05D1034314 Issued in CA
Legal business name
MITOMED DIAGNOSTICS LABORATORY
Practice address
2501 Hewitt HL
University of California Irvine
Irvine, CA 92697-0001
Phone
(949) 824-1886
Fax
(949) 824-6388
NPI assigned
Nov 7, 2008
Last updated
Nov 7, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 7, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Prof. Douglas C. Wallace, PHDNPI 1811181498
Title
Laboratory Director
Phone
(949) 824-3490

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Medical Laboratory 291U00000X 05D1034314 CA Primary

Addresses

Primary practice location

2501 Hewitt HL
University of California Irvine
Irvine, CA 92697-0001

Mailing address

2501 Hewitt HL
University of California Irvine
Irvine, CA 92697-0001
Phone (949) 824-1886

Other identifiers 1

IdentifierTypeStateIssuer
05D1034314OtherCACLIA

National Provider Directory

National Provider Directory
Tax ID family
Uci Student Health Center Pharmacy42 organizations share this tax ID, including this one

Other organizations with this tax ID 41

Organizations that report the same tax identification number in the National Provider Directory.

View all 41

Locations

2501 Hewitt Hl
Irvine, CA 92697
Phone (949) 824-1886

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1226016000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1226016000000",
    "number": "1356595011",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2501 HEWITT HL",
            "address_2": "UNIVERSITY OF CALIFORNIA IRVINE",
            "city": "IRVINE",
            "state": "CA",
            "postal_code": "926970001",
            "telephone_number": "949-824-1886",
            "fax_number": "949-824-6388"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2501 HEWITT HL",
            "address_2": "UNIVERSITY OF CALIFORNIA IRVINE",
            "city": "IRVINE",
            "state": "CA",
            "postal_code": "926970001",
            "telephone_number": "949-824-1886",
            "fax_number": "949-824-6388"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MITOMED DIAGNOSTICS LABORATORY",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-11-07",
        "last_updated": "2008-11-07",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "DOUGLAS",
        "authorized_official_middle_name": "C.",
        "authorized_official_title_or_position": "LABORATORY DIRECTOR",
        "authorized_official_telephone_number": "949-824-3490",
        "authorized_official_name_prefix": "Prof.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "CA",
            "license": "05D1034314",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA",
            "identifier": "05D1034314",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Irvine, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 7, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.