Provider Demographics
NPI:1275613374
Name:DE LA MAZA, LUIS M (MD)
Entity type:Individual
Prefix:
First Name:LUIS M
Middle Name:
Last Name:DE LA MAZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UCI DEPARTMENT OF PATHOLOGY
Mailing Address - Street 2:PO BOX 513377
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3377
Mailing Address - Country:US
Mailing Address - Phone:714-456-2986
Mailing Address - Fax:
Practice Address - Street 1:UCI MEDICAL CENTER
Practice Address - Street 2:101 THE CITY DRIVE SOUTH
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-456-2986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000000A35127207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A351270Medicaid
CAWA35127AOtherMEDICARE PTAN
CA00A351270OtherBLUE SHIELD
CAWA35127AMedicare PIN
CAE98631Medicare UPIN