Provider Demographics
NPI:1083911622
Name:LITTLE ELM FRISCO CHILDREN'S CLINIC
Entity Type:Organization
Organization Name:LITTLE ELM FRISCO CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PREM
Authorized Official - Middle Name:P
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-494-4622
Mailing Address - Street 1:12398 FM 423
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-0158
Mailing Address - Country:US
Mailing Address - Phone:214-494-4622
Mailing Address - Fax:214-494-4609
Practice Address - Street 1:12398 FM 423
Practice Address - Street 2:SUITE 600
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-0158
Practice Address - Country:US
Practice Address - Phone:214-494-4622
Practice Address - Fax:214-494-4609
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE ELM-FRISCO CHILDREN'S CLINIC PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-17
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7772208000000X, 208000000X
TXF8878208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24778Medicaid
TX126877306Medicaid
TX220282201Medicaid
TX133070608Medicaid
TX220282202Medicaid