Provider Demographics
NPI:1578717674
Name:HISTOLOGY CYTOLOGY TECHNICAL LAB OF NORTH MISSISSIPPI
Entity Type:Organization
Organization Name:HISTOLOGY CYTOLOGY TECHNICAL LAB OF NORTH MISSISSIPPI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FULLENWIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-362-0858
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-0428
Mailing Address - Country:US
Mailing Address - Phone:662-232-8121
Mailing Address - Fax:662-236-5236
Practice Address - Street 1:2301 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5373
Practice Address - Country:US
Practice Address - Phone:662-232-8121
Practice Address - Fax:662-236-5236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11854207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty