Healthcare Provider Details

I. General information

NPI: 1841632783
Provider Name (Legal Business Name): DERMPATH AND DERM CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 SCOTT BLVD
DECATUR GA
30030-1424
US

IV. Provider business mailing address

1428 SCOTT BLVD
DECATUR GA
30030-1424
US

V. Phone/Fax

Practice location:
  • Phone: 678-904-4932
  • Fax: 404-370-0428
Mailing address:
  • Phone: 678-904-4932
  • Fax: 404-370-0428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number27516
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number053035
License Number StateGA

VIII. Authorized Official

Name: DR. KATHLEEN J SMITH
Title or Position: OWNER
Credential: MD
Phone: 404-291-0379