Provider Demographics
NPI:1821340472
Name:FAIRWAY PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:FAIRWAY PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-855-2073
Mailing Address - Street 1:4100 FAIRWAY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6525
Mailing Address - Country:US
Mailing Address - Phone:972-492-8880
Mailing Address - Fax:972-492-8818
Practice Address - Street 1:4100 FAIRWAY DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6525
Practice Address - Country:US
Practice Address - Phone:972-492-8880
Practice Address - Fax:972-492-8818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-06
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6737208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3079857-01Medicaid