Provider Demographics
NPI:1063632891
Name:PEDIATRIC DIAGNOSTIC SERVICES, PA
Entity Type:Organization
Organization Name:PEDIATRIC DIAGNOSTIC SERVICES, PA
Other - Org Name:KID'S KLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ILDIKO
Authorized Official - Middle Name:G
Authorized Official - Last Name:EDENHOFFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-969-4230
Mailing Address - Street 1:1141 KINWEST PKWY STE 150
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3513
Mailing Address - Country:US
Mailing Address - Phone:972-969-4230
Mailing Address - Fax:972-409-9016
Practice Address - Street 1:1141 KINWEST PKWY STE 150
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3513
Practice Address - Country:US
Practice Address - Phone:972-969-4230
Practice Address - Fax:214-496-0267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7475174400000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty