Provider Demographics
NPI:1154436897
Name:MEDICAL DIAGNOSTIC LABORATORIES
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTIC LABORATORIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-473-6555
Mailing Address - Street 1:3116 W MARCH LN STE 200
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2370
Mailing Address - Country:US
Mailing Address - Phone:209-473-6555
Mailing Address - Fax:209-473-6544
Practice Address - Street 1:3116 W MARCH LN STE 200
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2370
Practice Address - Country:US
Practice Address - Phone:209-473-6555
Practice Address - Fax:209-473-6544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54073207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G540730Medicaid
CAG54073OtherCA LICENSE #
CA00G540730Medicare ID - Type Unspecified
CAA52650Medicare UPIN