Provider Demographics
NPI:1013922731
Name:MD PEDIATRIC ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:MD PEDIATRIC ASSOCIATES, P.A.
Other - Org Name:MD PEDIATRIC ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-420-1475
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-8429
Mailing Address - Country:US
Mailing Address - Phone:972-420-1475
Mailing Address - Fax:214-222-2435
Practice Address - Street 1:760 N DENTON TAP RD
Practice Address - Street 2:SUITE 130
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-2163
Practice Address - Country:US
Practice Address - Phone:972-420-1475
Practice Address - Fax:214-222-2435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID#