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Organization
NORTHSIDE PATHOLOGY GROUP, PLLC
Active
Organization
NORTHSIDE PATHOLOGY GROUP, PLLC
Active
Other names
NPG
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARIO CERVANTES-VAZQUEZ M.D. (PRESIDENT / MANAGER MEMBER)
(832) 638-6072
Entity
Organization
Contact information
Practice address
510 W TIDWELL RD, PATHOLOGY DEPT., HOUSTON, TX 77091-4339
(281) 618-8504
(713) 401-0770
Mailing address
510 W TIDWELL RD, HOUSTON, TX 77091-4339
(281) 618-8515
(281) 618-8634
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
217596001
—
TX
01
—
45D2028677
CLIA
TX
01
—
TXB104047
MEDICARE GROUP PTAN
TX
Enumeration date
04/26/2010
Last updated
04/21/2020
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