Provider Demographics
NPI:1003028879
Name:BOYS & GIRLS PEDIATRIC CLINIC PA
Entity Type:Organization
Organization Name:BOYS & GIRLS PEDIATRIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VAHID
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRAFZALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-831-0880
Mailing Address - Street 1:5850 FM802 SUITE C 6-7
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-5203
Mailing Address - Country:US
Mailing Address - Phone:956-831-0880
Mailing Address - Fax:956-831-0815
Practice Address - Street 1:5850 FM802
Practice Address - Street 2:SUITE C 6-7
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-5203
Practice Address - Country:US
Practice Address - Phone:956-831-0880
Practice Address - Fax:956-831-0815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6156208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG83965Medicare UPIN