Provider Demographics
NPI:1760520555
Name:PHYSICIANS PATHOLOGY INC
Entity Type:Organization
Organization Name:PHYSICIANS PATHOLOGY INC
Other - Org Name:SANDRA K DIMMITT MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:DIMMITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-247-6558
Mailing Address - Street 1:17936 S 273RD W AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010
Mailing Address - Country:US
Mailing Address - Phone:918-247-6558
Mailing Address - Fax:918-247-6558
Practice Address - Street 1:17936 S 273RD W AVE
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:OK
Practice Address - Zip Code:74010
Practice Address - Country:US
Practice Address - Phone:918-247-6558
Practice Address - Fax:918-247-6558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11700207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F03198Medicare UPIN