Provider Demographics
NPI:1346223377
Name:PINKUS DERMATOPATHOLOGY LABORATORY, PC
Entity Type:Organization
Organization Name:PINKUS DERMATOPATHOLOGY LABORATORY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLADARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-514-5822
Mailing Address - Street 1:1355 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4915
Mailing Address - Country:US
Mailing Address - Phone:734-242-6872
Mailing Address - Fax:734-242-4962
Practice Address - Street 1:1314 N MACOMB ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3131
Practice Address - Country:US
Practice Address - Phone:734-242-6872
Practice Address - Fax:734-242-4962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1017853Medicaid
MI1017853Medicaid