Provider Demographics
NPI:1356595011
Name:MITOMED DIAGNOSTICS LABORATORY
Entity type:Organization
Organization Name:MITOMED DIAGNOSTICS LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:949-824-3490
Mailing Address - Street 1:2501 HEWITT HL
Mailing Address - Street 2:UNIVERSITY OF CALIFORNIA IRVINE
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92697-0001
Mailing Address - Country:US
Mailing Address - Phone:949-824-1886
Mailing Address - Fax:949-824-6388
Practice Address - Street 1:2501 HEWITT HL
Practice Address - Street 2:UNIVERSITY OF CALIFORNIA IRVINE
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92697-0001
Practice Address - Country:US
Practice Address - Phone:949-824-1886
Practice Address - Fax:949-824-6388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D1034314291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D1034314OtherCLIA