Provider Demographics
NPI:1588879373
Name:REDWOOD DERMATOPATHOLOGY LABORATORY
Entity type:Organization
Organization Name:REDWOOD DERMATOPATHOLOGY LABORATORY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUGARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-545-4537
Mailing Address - Street 1:2725 MENDOCINO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2805
Mailing Address - Country:US
Mailing Address - Phone:707-545-4537
Mailing Address - Fax:707-545-6726
Practice Address - Street 1:2725 MENDOCINO AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2805
Practice Address - Country:US
Practice Address - Phone:707-545-4537
Practice Address - Fax:707-545-6726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 329844291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory