Basic Information
| Provider Information | |||||||||
| NPI: | 1003413139 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTWATER DIAGNOSTICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3732 GLEN HAVEN BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770251205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135596929 | ||||||||
| FaxNumber: | 7135596928 | ||||||||
| Practice Location | |||||||||
| Address1: | 3732 GLEN HAVEN BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770251205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135596929 | ||||||||
| FaxNumber: | 7135596928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2020 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEKMEZIAN | ||||||||
| AuthorizedOfficialFirstName: | MHAIR | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZING OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7135596929 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.