Organization
M D TOXICOLOGY GROUP, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK NICKLE (ADMINISTRATOR)
(210) 882-1705
Entity
Organization
Contact information
Practice address
11827 STARCREST DR, SAN ANTONIO, TX 78247-4113
(512) 531-9214
Mailing address
11827 STARCREST DR, SAN ANTONIO, TX 78247-4113
(512) 531-9214
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
498429
MEDICARE
TX
01
—
CL5776
BC/BS OF TX
TX
Enumeration date
02/05/2016
Last updated
05/19/2016
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