Provider Demographics
NPI:1578656096
Name:LAKE POINTE PEDIATRIC ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:LAKE POINTE PEDIATRIC ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:MARION MARGARET
Authorized Official - Last Name:WIELAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-412-1034
Mailing Address - Street 1:6900 SCENIC DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-2695
Mailing Address - Country:US
Mailing Address - Phone:972-412-1034
Mailing Address - Fax:972-475-5708
Practice Address - Street 1:6900 SCENIC DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-2695
Practice Address - Country:US
Practice Address - Phone:972-412-1034
Practice Address - Fax:972-475-5708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5394208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0036CVOtherBLUE CROSS OF TEXAS