Provider Demographics
NPI:1497790703
Name:PEDIATRIC INSTITUTE OF SOUTHWEST TEXAS,P.A.
Entity Type:Organization
Organization Name:PEDIATRIC INSTITUTE OF SOUTHWEST TEXAS,P.A.
Other - Org Name:KUBENA PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KASSIA
Authorized Official - Middle Name:LOUEVA
Authorized Official - Last Name:KUBENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:210-877-9966
Mailing Address - Street 1:5255 PRUE RD
Mailing Address - Street 2:SUITE #105
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1335
Mailing Address - Country:US
Mailing Address - Phone:210-877-9966
Mailing Address - Fax:210-877-1162
Practice Address - Street 1:5255 PRUE RD
Practice Address - Street 2:SUITE #105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1335
Practice Address - Country:US
Practice Address - Phone:210-877-9966
Practice Address - Fax:210-877-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169084401Medicaid
TX0051LZOtherBLUE CROSS ID NUMBER
TX0051LZOtherBLUE CROSS ID NUMBER
TX169084401Medicaid