Provider Demographics
NPI:1366863318
Name:SAN FRANCISCO DERMATOPATHOLOGY INSTITUTE PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SAN FRANCISCO DERMATOPATHOLOGY INSTITUTE PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-413-6100
Mailing Address - Street 1:1618 SULLIVAN AVE.
Mailing Address - Street 2:SUITE 105
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-1968
Mailing Address - Country:US
Mailing Address - Phone:650-756-5500
Mailing Address - Fax:
Practice Address - Street 1:1618 SULLIVAN AVE.
Practice Address - Street 2:SUITE 105
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-1968
Practice Address - Country:US
Practice Address - Phone:650-756-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF00345457291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory