Healthcare Provider Details

I. General information

NPI: 1508101007
Provider Name (Legal Business Name): UNITED PATHOLOGIST LABORATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 W DR MARTIN LUTHER KING JR BLVD
TAMPA FL
33603-3450
US

IV. Provider business mailing address

612 PALMETTO ST
NEW SMYRNA BEACH FL
32168-7327
US

V. Phone/Fax

Practice location:
  • Phone: 386-423-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number800020973
License Number StateFL

VIII. Authorized Official

Name: DR. MARK NAGRANI
Title or Position: PRESIDENT
Credential: MD
Phone: 386-423-5500