Provider Demographics
NPI:1790783074
Name:MEDICAL DIAGNOSTIC SERVICES LLP
Entity Type:Organization
Organization Name:MEDICAL DIAGNOSTIC SERVICES LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:ROLANDO
Authorized Official - Last Name:CONTRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-448-4319
Mailing Address - Street 1:PO BOX 5628
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5628
Mailing Address - Country:US
Mailing Address - Phone:765-448-4319
Mailing Address - Fax:765-448-2921
Practice Address - Street 1:2400 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3027
Practice Address - Country:US
Practice Address - Phone:765-448-4319
Practice Address - Fax:765-448-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========001OtherANTHEM
IN=========001OtherTRICARE
IN=========003OtherTRICARE
IN=========003OtherANTHEM
IN=========002OtherANTHEM
IN=========002OtherTRICARE
IN=========002OtherANTHEM
IN=========002OtherTRICARE
IN=========003OtherANTHEM