Provider Demographics
NPI:1518307529
Name:TEXOMA PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:TEXOMA PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMULESCU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-920-1980
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74702-0128
Mailing Address - Country:US
Mailing Address - Phone:580-920-1980
Mailing Address - Fax:580-920-9937
Practice Address - Street 1:430 BRYAN DR
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3467
Practice Address - Country:US
Practice Address - Phone:580-920-1980
Practice Address - Fax:580-920-9937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-05
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4154208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200053590CMedicaid
OKI36843OtherNPI
OK200285150BMedicaid
OK200053590CMedicaid
OK200285150BMedicaid
OKOKA102860Medicare PIN