Provider Demographics
NPI:1235469685
Name:OC PATH MEDICAL GROUP
Entity Type:Organization
Organization Name:OC PATH MEDICAL GROUP
Other - Org Name:ORANGE REGIONAL PATHOLOGY ASSOCIATE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:P
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-633-0011
Mailing Address - Street 1:PO BOX 10076
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91410-0076
Mailing Address - Country:US
Mailing Address - Phone:805-578-8300
Mailing Address - Fax:805-578-3911
Practice Address - Street 1:3350 W BALL RD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3710
Practice Address - Country:US
Practice Address - Phone:714-827-6701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0582538207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20171Medicare PIN