Provider Demographics
NPI:1235135252
Name:GEORGIA DERMATOPATHOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:GEORGIA DERMATOPATHOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:404-371-0077
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47702-0265
Mailing Address - Country:US
Mailing Address - Phone:812-471-1591
Mailing Address - Fax:812-471-6650
Practice Address - Street 1:1610 LAVISTA RD NE STE 4
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4316
Practice Address - Country:US
Practice Address - Phone:404-371-0077
Practice Address - Fax:404-371-1900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA145104291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA22BDDJPMedicare ID - Type Unspecified