Provider Demographics
NPI:1861858367
Name:PRIME PEDIATRICS
Entity Type:Organization
Organization Name:PRIME PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAN
Authorized Official - Middle Name:BABU
Authorized Official - Last Name:RAYALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-271-8050
Mailing Address - Street 1:2005 E GRIFFIN PKWY
Mailing Address - Street 2:193
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-3222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 E GRIFFIN PKWY
Practice Address - Street 2:193
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-3222
Practice Address - Country:US
Practice Address - Phone:956-271-8050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6091208000000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty