Provider Demographics
NPI:1386833374
Name:DALLAS PEDIATRICS & INFECTIOUS DISEASE ASSOCIATES
Entity Type:Organization
Organization Name:DALLAS PEDIATRICS & INFECTIOUS DISEASE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FARYAL
Authorized Official - Middle Name:ABDUL
Authorized Official - Last Name:GHAFFAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-416-5554
Mailing Address - Street 1:1120 S MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-5543
Mailing Address - Country:US
Mailing Address - Phone:817-416-5554
Mailing Address - Fax:817-416-5556
Practice Address - Street 1:1120 S MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5543
Practice Address - Country:US
Practice Address - Phone:817-416-5554
Practice Address - Fax:817-416-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9784208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175070501Medicaid
TX0088MQOtherBLUE SHIELD
TX175070502Medicaid
TX175070501Medicaid