Healthcare Provider Details

I. General information

NPI: 1790783074
Provider Name (Legal Business Name): MEDICAL DIAGNOSTIC SERVICES LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 SOUTH ST
LAFAYETTE IN
47904-3027
US

IV. Provider business mailing address

PO BOX 5628
LAFAYETTE IN
47903-5628
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-4319
  • Fax: 765-448-2921
Mailing address:
  • Phone: 765-448-4319
  • Fax: 765-448-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: MARIO ROLANDO CONTRERAS
Title or Position: PARTNER
Credential:
Phone: 765-448-4319