Provider Demographics
NPI:1942307178
Name:BREVARD DERMPATH AND SURGPATH LAB INC
Entity Type:Organization
Organization Name:BREVARD DERMPATH AND SURGPATH LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMANT
Authorized Official - Middle Name:
Authorized Official - Last Name:PANDYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-702-5135
Mailing Address - Street 1:2555 PONCE DE LEON BLVD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-6010
Mailing Address - Country:US
Mailing Address - Phone:305-702-5135
Mailing Address - Fax:305-441-2144
Practice Address - Street 1:830 EXECUTIVE LN
Practice Address - Street 2:SUITE #150
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3595
Practice Address - Country:US
Practice Address - Phone:305-702-5135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAI354Medicare PIN