Provider Demographics
NPI:1154445419
Name:EASTERN TEXAS PATHOLOGY LABORATORIES, LLC
Entity Type:Organization
Organization Name:EASTERN TEXAS PATHOLOGY LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:OGBURN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:903-675-0080
Mailing Address - Street 1:134 ROSEDALE DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3625
Mailing Address - Country:US
Mailing Address - Phone:903-675-0080
Mailing Address - Fax:903-675-0081
Practice Address - Street 1:134 ROSEDALE DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3625
Practice Address - Country:US
Practice Address - Phone:903-675-0080
Practice Address - Fax:903-675-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2242207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0085PVOtherBCBS
TXCL8659Medicare PIN