1265431456 NPI number — SOUTH TEXAS DERMATOPATHOLOGY LAB PA

Table of content: (NPI 1265431456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265431456 NPI number — SOUTH TEXAS DERMATOPATHOLOGY LAB PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH TEXAS DERMATOPATHOLOGY LAB PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265431456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1122 AUSTIN HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78209-4844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-342-6488
Provider Business Mailing Address Fax Number:
210-342-6725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1122 AUSTIN HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78209-4844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-342-6488
Provider Business Practice Location Address Fax Number:
210-342-6725
Provider Enumeration Date:
07/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
LABORATORY DIRECTOR
Authorized Official Telephone Number:
210-342-6488

Provider Taxonomy Codes

  • Taxonomy code: 207ZD0900X , with the licence number:  G4960 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13211 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0421345 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110795501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100245340A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90013183 . This is a "PACIFICALE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 690004679 . This is a "MEDICARE RR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 912055600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116882 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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