Healthcare Provider Details

I. General information

NPI: 1013239219
Provider Name (Legal Business Name): SUNCOAST DERMPATH LABORATORY & CONSULTATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2010
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4431 WALTHAM DR
TAMPA FL
33634-7345
US

IV. Provider business mailing address

4431 WALTHAM DR
TAMPA FL
33634-7345
US

V. Phone/Fax

Practice location:
  • Phone: 813-598-2893
  • Fax: 888-427-8643
Mailing address:
  • Phone: 813-598-2893
  • Fax: 888-427-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberME99158
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME99158
License Number StateFL

VIII. Authorized Official

Name: DR. SHURUN ZHAO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 813-598-2893