Provider Demographics
NPI:1861043259
Name:PEDIATRIC DEPOT PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DEPOT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROSHNI
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:972-210-7350
Mailing Address - Street 1:3911 US HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-3351
Mailing Address - Country:US
Mailing Address - Phone:614-946-7674
Mailing Address - Fax:
Practice Address - Street 1:1446 W MOORE AVE STE 206
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160-2372
Practice Address - Country:US
Practice Address - Phone:972-210-7350
Practice Address - Fax:972-210-7355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-26
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty