Provider Demographics
NPI:1407191356
Name:HIGH DESERT PATHOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:HIGH DESERT PATHOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TADROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-843-6262
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 1:16850 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5794
Practice Address - Country:US
Practice Address - Phone:760-843-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0643174207ZP0102X
CA05D0563949207ZP0102X
CA05D0562204207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty