Provider Demographics
NPI:1245234616
Name:CERVANTES-VAZQUEZ, MARIO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:CERVANTES-VAZQUEZ
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:PO BOX 746559
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6559
Mailing Address - Country:US
Mailing Address - Phone:281-348-8279
Mailing Address - Fax:281-348-8275
Practice Address - Street 1:22999 HIGHWAY 59 N
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-4412
Practice Address - Country:US
Practice Address - Phone:281-348-8279
Practice Address - Fax:281-348-8275
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7953207ZH0000X, 207ZP0102X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220033031OtherRAILROAD MEDICARE
TX130817316Medicaid
TX8F10145Medicare PIN
TXF32320Medicare UPIN