Provider Demographics
NPI:1679594287
Name:MICROCORRE DIAGNOSTIC LABORATORY
Entity type:Organization
Organization Name:MICROCORRE DIAGNOSTIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-686-4000
Mailing Address - Street 1:890 N CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-2208
Mailing Address - Country:US
Mailing Address - Phone:559-686-4000
Mailing Address - Fax:559-686-9432
Practice Address - Street 1:890 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-2208
Practice Address - Country:US
Practice Address - Phone:559-686-4000
Practice Address - Fax:559-686-9432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF1717207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ58691ZMedicaid
CAZZZ58691ZMedicare PIN