Provider Demographics
NPI:1265431456
Name:SOUTH TEXAS DERMATOPATHOLOGY LAB PA
Entity type:Organization
Organization Name:SOUTH TEXAS DERMATOPATHOLOGY LAB PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-342-6488
Mailing Address - Street 1:1122 AUSTIN HWY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4844
Mailing Address - Country:US
Mailing Address - Phone:210-342-6488
Mailing Address - Fax:210-342-6725
Practice Address - Street 1:1122 AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4844
Practice Address - Country:US
Practice Address - Phone:210-342-6488
Practice Address - Fax:210-342-6725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4960207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13211Medicaid
MT0421345Medicaid
TX110795501Medicaid
KS100245340AMedicaid
TX90013183OtherPACIFICALE
TX690004679OtherMEDICARE RR
FL912055600Medicaid
MN116882Medicaid
TXCL0476Medicare ID - Type Unspecified