Provider Demographics
NPI:1316395395
Name:SACRAMENTO ADVANCED LAPAROSCOPIC SURGERY
Entity Type:Organization
Organization Name:SACRAMENTO ADVANCED LAPAROSCOPIC SURGERY
Other - Org Name:DONALD WALDREP, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDREP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-230-0030
Mailing Address - Street 1:110 JENSEN CT
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-7483
Mailing Address - Country:US
Mailing Address - Phone:805-230-0030
Mailing Address - Fax:805-230-2995
Practice Address - Street 1:110 JENSEN CT
Practice Address - Street 2:SUITE 1B
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7483
Practice Address - Country:US
Practice Address - Phone:805-230-0030
Practice Address - Fax:805-230-2995
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SACRAMENTO ADVANCED LAPAROSCOPIC SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-31
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75982208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG52375Medicare UPIN