Provider Demographics
NPI:1255862074
Name:PEDICARE CHILDRENS CLINIC PA
Entity Type:Organization
Organization Name:PEDICARE CHILDRENS CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KINGSLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:OKONKWO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-334-0613
Mailing Address - Street 1:2101 N MIDLAND DR STE 14A
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-5507
Mailing Address - Country:US
Mailing Address - Phone:432-695-6300
Mailing Address - Fax:432-695-6571
Practice Address - Street 1:2101 N MIDLAND DR STE 14A
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-5507
Practice Address - Country:US
Practice Address - Phone:432-695-6300
Practice Address - Fax:326-956-5714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5518208000000X
TXP4362208000000X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP4362OtherSTATE LICENSE
TXAP144543OtherALL
TXQ5518OtherSTATE LICENSE