1356374912 NPI number — DERMATOPATHOLOGY ASSOCIATES, PLLC

Table of content: (NPI 1356374912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356374912 NPI number — DERMATOPATHOLOGY ASSOCIATES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOPATHOLOGY ASSOCIATES, PLLC
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:
1356374912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3528
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39207-3528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-362-9851
Provider Business Mailing Address Fax Number:
601-982-9025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3120 OLD CANTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-362-9851
Provider Business Practice Location Address Fax Number:
601-982-9025
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUONG
Authorized Official First Name:
BUU
Authorized Official Middle Name:
T
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
601-362-9851

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  25D0688888 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1964310 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 690008330 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00120024 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009931780 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135488709 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640399351A . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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