Healthcare Provider Details

I. General information

NPI: 1043089246
Provider Name (Legal Business Name): NTX PATHOLOGY PROGRAM, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2023
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W MAIN ST
LEWISVILLE TX
75057-3641
US

IV. Provider business mailing address

PO BOX 745390
ATLANTA GA
30374-5390
US

V. Phone/Fax

Practice location:
  • Phone: 469-370-2280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JAMAINE DAVIS
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 561-402-4256