Provider Demographics
NPI:1013492420
Name:PEDS CENTER OF ROUND ROCK PA
Entity Type:Organization
Organization Name:PEDS CENTER OF ROUND ROCK PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIVEKANAND
Authorized Official - Middle Name:
Authorized Official - Last Name:DASARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-289-7621
Mailing Address - Street 1:1701 N LOOP 250 W
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-6002
Mailing Address - Country:US
Mailing Address - Phone:432-522-5033
Mailing Address - Fax:432-522-5077
Practice Address - Street 1:1701 N LOOP 250 W
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-6002
Practice Address - Country:US
Practice Address - Phone:432-522-5033
Practice Address - Fax:432-522-5077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty