Basic Information
Provider Information | |||||||||
NPI: | 1528030897 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DIAGNOSTIC PATHOLOGY SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14275 MIDWAY DRIVE | ||||||||
Address2: | SUITE 400 | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750013676 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2149328095 | ||||||||
FaxNumber: | 6102714245 | ||||||||
Practice Location | |||||||||
Address1: | 3300 NW EXPRESSWAY | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731124418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058422061 | ||||||||
FaxNumber: | 6102714245 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2006 | ||||||||
LastUpdateDate: | 11/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOLAN | ||||||||
AuthorizedOfficialFirstName: | KRISTIE | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8666978378 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 37D0470743 | 01 | OK | CLIA | OTHER | 37D0663764 | 01 | OK | CLIA | OTHER | 37D0470622 | 01 | OK | CLIA | OTHER | 37D0471000 | 01 | OK | CLIA | OTHER | 100758600B | 05 | OK |   | MEDICAID |