Provider Demographics
NPI:1083810022
Name:CIMO, MICHAEL LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEWIS
Last Name:CIMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 8TH AVENUE
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4110
Mailing Address - Country:US
Mailing Address - Phone:817-922-1559
Mailing Address - Fax:817-927-6296
Practice Address - Street 1:1400 8TH AVENUE
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-922-1559
Practice Address - Fax:817-927-6296
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3500207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K0257Medicare PIN