Provider Demographics
NPI:1700221918
Name:PEDERSEN, KATHLEEN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W AIRPORT FWY
Mailing Address - Street 2:SUITE 143
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-6203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 W AIRPORT FWY
Practice Address - Street 2:SUITE 143
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-6203
Practice Address - Country:US
Practice Address - Phone:469-488-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics