Provider Demographics
NPI:1235508805
Name:NASA PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:NASA PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IDALIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-464-3780
Mailing Address - Street 1:P.O. BOX 890004
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77289
Mailing Address - Country:US
Mailing Address - Phone:713-239-0980
Mailing Address - Fax:281-464-3832
Practice Address - Street 1:4014 WOODLAWN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504
Practice Address - Country:US
Practice Address - Phone:713-239-0980
Practice Address - Fax:281-464-3832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-24
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5879174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2130981Medicaid