Provider Demographics
NPI:1114916855
Name:C-S AND J PATHOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:C-S AND J PATHOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:COOPER-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-652-1516
Mailing Address - Street 1:352 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-2322
Mailing Address - Country:US
Mailing Address - Phone:805-652-1516
Mailing Address - Fax:805-652-2157
Practice Address - Street 1:2170 SOUTH AVE
Practice Address - Street 2:BARTON MEMORIAL HOSPITAL-PATHOLOGY
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7026
Practice Address - Country:US
Practice Address - Phone:530-542-3000
Practice Address - Fax:530-543-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0016260Medicaid
NV2088350Medicaid
NV2088350Medicaid