Provider Demographics
NPI:1417006735
Name:PRIMARY CARE PEDIATRICS,PA
Entity Type:Organization
Organization Name:PRIMARY CARE PEDIATRICS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MINDA
Authorized Official - Middle Name:LAO
Authorized Official - Last Name:TOLEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-729-9200
Mailing Address - Street 1:8333 9TH AVE.
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642
Mailing Address - Country:US
Mailing Address - Phone:409-729-9200
Mailing Address - Fax:409-729-9235
Practice Address - Street 1:8333 9TH AVE.
Practice Address - Street 2:SUITE B
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642
Practice Address - Country:US
Practice Address - Phone:409-729-9200
Practice Address - Fax:409-729-9235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2487208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM2487OtherTEXAS LICENSE
TX178296302Medicaid
TX178296301Medicaid
TX178297101Medicaid
TX178296301Medicaid
TX178296302Medicaid