Organization
CENTRAL MEDICAL DIAGNOSTIC LABORATORY, INC
Active
Other names
Central Medical Laboratory
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHN CHATFIELD HISERODT M.D. (CEO)
(888) 257-3873
Entity
Organization
Contact information
Practice address
10554 PROGRESS WAY, SUITE J, CYPRESS, CA 90630-4724
(888) 257-3873
(714) 821-1910
Mailing address
10554 PROGRESS WAY, SUITE J, CYPRESS, CA 90630-4724
(888) 257-3873
(714) 821-1910
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
—
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
G77372
LIC# JOHN HISERODT MD
CA
05
—
LAB01869F
—
CA
01
—
ZZZ85259Z
BLUE SHIELD PROVIDER NUM
CA
Enumeration date
06/27/2006
Last updated
08/22/2020
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