Healthcare Provider Details

I. General information

NPI: 1114953338
Provider Name (Legal Business Name): DIAGNOSTIC PATHOLOGY LABORATORIES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 08/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

PO BOX 23650
NEWARK NJ
07189-0001
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-2000
  • Fax:
Mailing address:
  • Phone: 800-832-8244
  • Fax: 207-753-2012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5000700
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: JOSEPH M LOMBARDO
Title or Position: CHIEF
Credential: MD
Phone: 201-996-2000