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General NPI Number Information
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NPI Number | 1649597931
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Entity Type | Organization
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Legal Business Name | NORTHSIDE PATHOLOGY GROUP, PLLC
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Dates
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Enumeration Date | 04/26/2010
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Last Update Date | 04/21/2020
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Provider Practice Location Address
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Address Line | 510 W TIDWELL RD PATHOLOGY DEPT.
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City | HOUSTON
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State | TX
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Zip | 77091-4339
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Country | US
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Telephone | 281-618-8504
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Fax | 713-401-0770
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Provider Business Mailing Address
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Address Line | 510 W TIDWELL RD
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City | HOUSTON
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State | TX
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Zip | 77091-4339
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Country | US
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Telephone | 281-618-8515
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Fax | 281-618-8634
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Authorized Official
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Title or Position | PRESIDENT / MANAGER MEMBER
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Name | DR. MARIO CERVANTES-VAZQUEZ
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Credential | M.D.
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Telephone | 832-638-6072
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number |
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License Number State |
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