Provider Demographics
NPI:1356374912
Name:DERMATOPATHOLOGY ASSOCIATES, PLLC
Entity type:Organization
Organization Name:DERMATOPATHOLOGY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BUU
Authorized Official - Middle Name:T
Authorized Official - Last Name:DUONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-362-9851
Mailing Address - Street 1:PO BOX 3528
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39207-3528
Mailing Address - Country:US
Mailing Address - Phone:601-362-9851
Mailing Address - Fax:601-982-9025
Practice Address - Street 1:3120 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-362-9851
Practice Address - Fax:601-982-9025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO25D0688888291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1964310Medicaid
MS00120024Medicaid
690008330OtherRAILROAD MEDICARE
AR135488709Medicaid
AL009931780Medicaid
640399351AOtherBLUE CROSS BLUE SHIELD
AR135488709Medicaid
MS00120024Medicaid