Provider Demographics
NPI:1487807343
Name:DIGESTIVE DISEASE PATHOLOGY LLC
Entity type:Organization
Organization Name:DIGESTIVE DISEASE PATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-767-6630
Mailing Address - Street 1:5015 N PENN AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-8891
Mailing Address - Country:US
Mailing Address - Phone:405-767-6630
Mailing Address - Fax:405-767-1176
Practice Address - Street 1:3366 NW EXPRESSWAY
Practice Address - Street 2:SUITE 350
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4462
Practice Address - Country:US
Practice Address - Phone:405-767-6630
Practice Address - Fax:405-767-1176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37D1088518OtherCLIA NUMBER