1548271794 NPI number — DERMPATH PLUS INC

Table of content: (NPI 1548271794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548271794 NPI number — DERMPATH PLUS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMPATH PLUS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548271794
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
829 GOLF ISLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APOLLO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33572-2781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-641-0130
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5946 FROND WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APOLLO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33572-2647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-641-0466
Provider Business Practice Location Address Fax Number:
813-641-0488
Provider Enumeration Date:
08/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAY
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
MEDICAL DIRECTOR PRESIDENT
Authorized Official Telephone Number:
813-760-5104

Provider Taxonomy Codes

  • Taxonomy code: 207ZD0900X , with the licence number:  MD022804 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207ZD0900X , with the licence number: M8087 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207ZP0102X , with the licence number: ME86922 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 16802 . This is a "BSBC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".