Provider Demographics
NPI:1295772416
Name:VERSALOVIC, JAMES (MD PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:VERSALOVIC
Suffix:
Gender:M
Credentials:MD PHD
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 741169
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77274-1169
Mailing Address - Country:US
Mailing Address - Phone:832-824-1866
Mailing Address - Fax:832-825-1032
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2399
Practice Address - Country:US
Practice Address - Phone:832-824-1866
Practice Address - Fax:832-825-1032
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4157207ZP0007X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154157501Medicaid
TX154157502OtherCIDC
TX154157502OtherCIDC
G71691Medicare UPIN
TXPOOO20865Medicare PIN