Healthcare Provider Details

I. General information

NPI: 1255964185
Provider Name (Legal Business Name): PINKUS DERMATOPATHOLOGY LABORATORY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 N MACOMB ST
MONROE MI
48162-3131
US

IV. Provider business mailing address

11025 RCA CENTER DR STE 300
PALM BEACH GARDENS FL
33410-4269
US

V. Phone/Fax

Practice location:
  • Phone: 616-530-1860
  • Fax:
Mailing address:
  • Phone: 561-514-5822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DINA VALLADARES
Title or Position: DIRECTOR, PAYER ENROLLMENT
Credential:
Phone: 561-514-5822