Provider Demographics
NPI:1609110832
Name:SHINE PEDIATRICS AND WELLNESS CENTER P.A.
Entity Type:Organization
Organization Name:SHINE PEDIATRICS AND WELLNESS CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:NAIDOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-939-6336
Mailing Address - Street 1:3600 SHIRE BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2240
Mailing Address - Country:US
Mailing Address - Phone:469-333-1543
Mailing Address - Fax:877-878-9118
Practice Address - Street 1:3600 SHIRE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2240
Practice Address - Country:US
Practice Address - Phone:469-333-1543
Practice Address - Fax:877-878-9118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-09
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0506208000000X
208000000X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty