Provider Demographics
NPI:1700273315
Name:MEDICAL DIAGNOSTIC LABORATORIES
Entity Type:Organization
Organization Name:MEDICAL DIAGNOSTIC LABORATORIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-406-8938
Mailing Address - Street 1:385 WOODVIEW AVE
Mailing Address - Street 2:SUITE # 175
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-2891
Mailing Address - Country:US
Mailing Address - Phone:209-406-8938
Mailing Address - Fax:408-636-7021
Practice Address - Street 1:385 WOODVIEW AVE
Practice Address - Street 2:SUITE # 175
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-2891
Practice Address - Country:US
Practice Address - Phone:209-406-8938
Practice Address - Fax:408-636-7021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54073207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty