Provider Demographics
NPI:1790018331
Name:FRY ROAD PEDIATRICS P.A
Entity Type:Organization
Organization Name:FRY ROAD PEDIATRICS P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IFTHEKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:UNNISSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-578-9766
Mailing Address - Street 1:21372 PROVINCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-7580
Mailing Address - Country:US
Mailing Address - Phone:281-578-9766
Mailing Address - Fax:281-578-6540
Practice Address - Street 1:21372 PROVINCIAL BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-7580
Practice Address - Country:US
Practice Address - Phone:281-578-9766
Practice Address - Fax:281-578-6540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty