Provider Demographics
NPI:1376676403
Name:THE WEST COVINA KIDS DOC ,APMC
Entity Type:Organization
Organization Name:THE WEST COVINA KIDS DOC ,APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PANKAJ
Authorized Official - Middle Name:N
Authorized Official - Last Name:MISTRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-919-5437
Mailing Address - Street 1:PO BOX 4219
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-0219
Mailing Address - Country:US
Mailing Address - Phone:626-919-5437
Mailing Address - Fax:626-919-5439
Practice Address - Street 1:933 S SUNSET AVE
Practice Address - Street 2:SUITE # 101
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3410
Practice Address - Country:US
Practice Address - Phone:626-919-5437
Practice Address - Fax:626-919-5439
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE KIDS DOC APMC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-14
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366518342OtherNPI NUMBER