Healthcare Provider Details

I. General information

NPI: 1235135252
Provider Name (Legal Business Name): GEORGIA DERMATOPATHOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 LAVISTA RD NE STE 4
ATLANTA GA
30329-4316
US

IV. Provider business mailing address

PO BOX 265
EVANSVILLE IN
47702-0265
US

V. Phone/Fax

Practice location:
  • Phone: 404-371-0077
  • Fax: 404-371-1900
Mailing address:
  • Phone: 812-471-1591
  • Fax: 812-471-6650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number145104
License Number StateGA

VIII. Authorized Official

Name: DR. MICHAEL SCOTT HOWARD IV
Title or Position: PRESIDENT
Credential: MD
Phone: 404-371-0077