Provider Demographics
NPI:1255332714
Name:UNIVERSAL DIAGNOSTIC LABORATORIES, INC.
Entity Type:Organization
Organization Name:UNIVERSAL DIAGNOSTIC LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-859-4777
Mailing Address - Street 1:1414 NEWKIRK AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-6522
Mailing Address - Country:US
Mailing Address - Phone:718-859-4777
Mailing Address - Fax:718-859-4578
Practice Address - Street 1:1414 NEWKIRK AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-6522
Practice Address - Country:US
Practice Address - Phone:718-859-4777
Practice Address - Fax:718-859-4578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00289478Medicaid
NYL81831Medicare UPIN