Provider Demographics
NPI:1982619466
Name:SAN DIEGO PATHOLOGISTS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SAN DIEGO PATHOLOGISTS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:STAYBOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-325-8748
Mailing Address - Street 1:7592 METROPOLITAN DR
Mailing Address - Street 2:SUITE 405
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4428
Mailing Address - Country:US
Mailing Address - Phone:619-325-8726
Mailing Address - Fax:619-325-8728
Practice Address - Street 1:7592 METROPOLITAN DR
Practice Address - Street 2:SUITE 405-407
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4428
Practice Address - Country:US
Practice Address - Phone:619-297-4900
Practice Address - Fax:619-297-5460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Single Specialty
No207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ57609ZOtherBLUE SHIELD GROUP NUMBER
CAZZZ81205ZMedicaid
CAHW567Medicare PIN
CAZZZ81205ZMedicaid
CAZZZ57609ZOtherBLUE SHIELD GROUP NUMBER
CAHW567AMedicare PIN