Basic Information
| Provider Information | |||||||||
| NPI: | 1487807343 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGESTIVE DISEASE PATHOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5015 N PENN AVE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731128891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057676630 | ||||||||
| FaxNumber: | 4057671176 | ||||||||
| Practice Location | |||||||||
| Address1: | 3366 NW EXPRESSWAY | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057676630 | ||||||||
| FaxNumber: | 4057671176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2008 | ||||||||
| LastUpdateDate: | 10/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4057676630 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 37D1088518 | 01 | OK | CLIA NUMBER | OTHER |