Healthcare Provider Details

I. General information

NPI: 1124002837
Provider Name (Legal Business Name): BAYLOR DERMATOPATHOLOGY LABORATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 03/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6535 FANNIN ST
HOUSTON TX
77030-2703
US

IV. Provider business mailing address

PO BOX 4715
HOUSTON TX
77210-4715
US

V. Phone/Fax

Practice location:
  • Phone: 713-798-4133
  • Fax:
Mailing address:
  • Phone: 713-481-3544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID TITUS
Title or Position: AUTHORIZED REP.
Credential:
Phone: 713-481-3544