Provider Demographics
NPI:1750460093
Name:DELAWARE CLINICAL & LABORATORY PHYSICIANS, PA
Entity Type:Organization
Organization Name:DELAWARE CLINICAL & LABORATORY PHYSICIANS, PA
Other - Org Name:PATHOLOGY DCLP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WITKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-454-9830
Mailing Address - Street 1:PO BOX 12210
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19850-2210
Mailing Address - Country:US
Mailing Address - Phone:302-454-9830
Mailing Address - Fax:302-454-1445
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY & LABORATORY MEDICINE
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-0001
Practice Address - Country:US
Practice Address - Phone:302-454-9830
Practice Address - Fax:302-454-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE400302Medicaid
DE400302Medicaid