Provider Demographics
NPI:1043566086
Name:EASTERN PATHOLOGY
Entity Type:Organization
Organization Name:EASTERN PATHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:E
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-252-2673
Mailing Address - Street 1:148 LINDEN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6909
Mailing Address - Country:US
Mailing Address - Phone:540-504-0066
Mailing Address - Fax:540-678-9025
Practice Address - Street 1:94 BROOKSHIRE LN
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6765
Practice Address - Country:US
Practice Address - Phone:304-252-2673
Practice Address - Fax:304-929-2350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3910001297Medicaid
WVQ438440001Medicare PIN