Provider Demographics
NPI:1831684315
Name:MISSION DERMATOPATHOLOGY LABORATORY, LLC
Entity type:Organization
Organization Name:MISSION DERMATOPATHOLOGY LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:ALTMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-664-4675
Mailing Address - Street 1:2620 MCCULLOUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-3022
Mailing Address - Country:US
Mailing Address - Phone:210-664-4675
Mailing Address - Fax:
Practice Address - Street 1:2620 MCCULLOUGH AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3022
Practice Address - Country:US
Practice Address - Phone:210-314-9898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9998207N00000X, 207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty