Provider Demographics
NPI:1912691668
Name:MED DIAGNOSTIC LABORATORY TX INC
Entity Type:Organization
Organization Name:MED DIAGNOSTIC LABORATORY TX INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-369-7253
Mailing Address - Street 1:499 NW 70TH AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-7573
Mailing Address - Country:US
Mailing Address - Phone:954-369-7253
Mailing Address - Fax:
Practice Address - Street 1:26710 INTERSTATE 45 N STE C200
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-1019
Practice Address - Country:US
Practice Address - Phone:954-369-7253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory