Provider Demographics
NPI:1891848297
Name:LIVINGSTON PEDIATRIC CLINIC PA
Entity Type:Organization
Organization Name:LIVINGSTON PEDIATRIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLO
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAWNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-328-8812
Mailing Address - Street 1:400 OGLETREE DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-6783
Mailing Address - Country:US
Mailing Address - Phone:936-328-8812
Mailing Address - Fax:936-328-8815
Practice Address - Street 1:400 OGLETREE DR
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-6783
Practice Address - Country:US
Practice Address - Phone:936-328-8812
Practice Address - Fax:936-328-8815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
TXJ65002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169920902Medicaid
TX0045LZOtherBCBS GROUP NUMBER
TX169920901Medicaid