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General NPI Number Information
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NPI Number | 1760520555
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Entity Type | Organization
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Legal Business Name | PHYSICIANS PATHOLOGY INC
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Dates
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Enumeration Date | 02/02/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 17936 S 273RD W AVE
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City | BRISTOW
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State | OK
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Zip | 74010
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Country | US
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Telephone | 918-247-6558
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Fax | 918-247-6558
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Provider Business Mailing Address
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Address Line | 17936 S 273RD W AVE
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City | BRISTOW
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State | OK
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Zip | 74010
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Country | US
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Telephone | 918-247-6558
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Fax | 918-247-6558
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Authorized Official
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Title or Position | OWNER
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Name | SANDRA K DIMMITT
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Credential | MD
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Telephone | 918-247-6558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 11700
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License Number State | OK
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