Healthcare Provider Details

I. General information

NPI: 1912915828
Provider Name (Legal Business Name): DERMATOPATHOLOGY LABORATORY OF NEW ENGLAND PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 GREEN RD
MERIDEN CT
06450-6612
US

IV. Provider business mailing address

140 GREEN RD
MERIDEN CT
06450-6612
US

V. Phone/Fax

Practice location:
  • Phone: 203-630-2666
  • Fax: 203-630-2909
Mailing address:
  • Phone: 203-630-2666
  • Fax: 203-630-2909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCL0562
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number029159
License Number StateCT

VIII. Authorized Official

Name: PHILIP EDWIN SHAPIRO
Title or Position: PRESIDENT
Credential: MD
Phone: 208-630-2666