Provider Demographics
NPI:1740227115
Name:DOMINION PATHOLOGY LABORATORIES PC
Entity Type:Organization
Organization Name:DOMINION PATHOLOGY LABORATORIES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:757-664-7901
Mailing Address - Street 1:PO BOX 2453
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-2453
Mailing Address - Country:US
Mailing Address - Phone:757-664-7901
Mailing Address - Fax:757-664-9122
Practice Address - Street 1:733 BOUSH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1501
Practice Address - Country:US
Practice Address - Phone:757-664-7901
Practice Address - Fax:757-664-9122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004991427Medicaid
VA288617OtherANTHEM BCBS
VA288617OtherANTHEM BCBS