Provider Demographics
NPI:1710128582
Name:PEDIATRIC HOSPITAL CARE OF LAREDO
Entity Type:Organization
Organization Name:PEDIATRIC HOSPITAL CARE OF LAREDO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:R
Authorized Official - Last Name:VELASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-543-7247
Mailing Address - Street 1:5111 N 10TH ST # 281
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-2835
Mailing Address - Country:US
Mailing Address - Phone:877-543-7247
Mailing Address - Fax:956-994-0114
Practice Address - Street 1:5111 N 10TH ST # 281
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-2835
Practice Address - Country:US
Practice Address - Phone:877-543-7247
Practice Address - Fax:956-994-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-09
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2023699-01Medicaid