Provider Demographics
NPI:1952144875
Name:OLD DOMINION UNIVERSITY
Entity type:Organization
Organization Name:OLD DOMINION UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MOLLICA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:757-683-3459
Mailing Address - Street 1:4608 HAMPTON BLVD
Mailing Address - Street 2:2118 HEALTH SCIENCES BLDG
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508
Mailing Address - Country:US
Mailing Address - Phone:757-683-3247
Mailing Address - Fax:
Practice Address - Street 1:4111 MONARCH WAY
Practice Address - Street 2:ROOM 3104
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508
Practice Address - Country:US
Practice Address - Phone:757-683-5393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLD DOMINION UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty