Provider Demographics
NPI:1720053945
Name:WATAUGA PATHOLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:WATAUGA PATHOLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:SOIKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-431-6388
Mailing Address - Street 1:PO BOX 52990
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-0048
Mailing Address - Country:US
Mailing Address - Phone:864-223-3600
Mailing Address - Fax:864-223-6054
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-6388
Practice Address - Fax:423-431-6331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000020115207ZC0500X
TNMD0000015437207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3384912Medicaid
TN3386617Medicare PIN
TN3384912Medicaid