Healthcare Provider Details

I. General information

NPI: 1356374912
Provider Name (Legal Business Name): DERMATOPATHOLOGY ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 OLD CANTON RD
JACKSON MS
39216
US

IV. Provider business mailing address

PO BOX 3528
JACKSON MS
39207-3528
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-9851
  • Fax: 601-982-9025
Mailing address:
  • Phone: 601-362-9851
  • Fax: 601-982-9025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number25D0688888
License Number StateMO

VIII. Authorized Official

Name: BUU T DUONG
Title or Position: MEMBER
Credential: MD
Phone: 601-362-9851