Provider Demographics
NPI:1467637249
Name:PENINSULA HISTOPATHOLOGY LABORATORY, INC.
Entity Type:Organization
Organization Name:PENINSULA HISTOPATHOLOGY LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PANGANIBAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-866-8377
Mailing Address - Street 1:1322 WHITE OAKS RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-6723
Mailing Address - Country:US
Mailing Address - Phone:408-866-8377
Mailing Address - Fax:
Practice Address - Street 1:1322 WHITE OAKS RD
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-6723
Practice Address - Country:US
Practice Address - Phone:408-866-8377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-30
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0884822291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ43128ZMedicare PIN