Provider Demographics
NPI:1518325562
Name:M D TOXICOLOGY GROUP, LLC
Entity Type:Organization
Organization Name:M D TOXICOLOGY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-882-1705
Mailing Address - Street 1:11827 STARCREST DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-4113
Mailing Address - Country:US
Mailing Address - Phone:512-531-9214
Mailing Address - Fax:
Practice Address - Street 1:11827 STARCREST DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-4113
Practice Address - Country:US
Practice Address - Phone:512-531-9214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-05
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX498429OtherMEDICARE
TXCL5776OtherBC/BS OF TX