Provider Demographics
NPI:1417016833
Name:PATHOLOGY MEDICAL GROUP OF RIVERSIDE
Entity Type:Organization
Organization Name:PATHOLOGY MEDICAL GROUP OF RIVERSIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:OKADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-788-3243
Mailing Address - Street 1:PO BOX 260071
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-8071
Mailing Address - Country:US
Mailing Address - Phone:314-849-3535
Mailing Address - Fax:844-410-3800
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:RIVERSIDE COMMUNITY HOSPITAL
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501
Practice Address - Country:US
Practice Address - Phone:951-788-3243
Practice Address - Fax:951-788-3633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0102X
CAA55141207ZP0101X
CAG59121207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0087630Medicaid
CAZZZ32952ZMedicare ID - Type Unspecified