Provider Demographics
NPI:1164509337
Name:CALIFORNIA PACIFIC PATHOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:CALIFORNIA PACIFIC PATHOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MORETTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-641-6574
Mailing Address - Street 1:PO BOX 26060
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-6060
Mailing Address - Country:US
Mailing Address - Phone:415-600-2200
Mailing Address - Fax:415-750-5001
Practice Address - Street 1:3555 CESAR CHAVEZ
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-4403
Practice Address - Country:US
Practice Address - Phone:415-641-6574
Practice Address - Fax:415-641-6717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053731Medicaid
CAGR0053731Medicaid
CAZZZ17274ZMedicare PIN