Provider Demographics
NPI:1477938132
Name:PEDIAQ
Entity type:Organization
Organization Name:PEDIAQ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-984-3900
Mailing Address - Street 1:17101 PRESTON RD
Mailing Address - Street 2:STE 115
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1331
Mailing Address - Country:US
Mailing Address - Phone:214-984-3900
Mailing Address - Fax:972-294-3343
Practice Address - Street 1:17101 PRESTON RD
Practice Address - Street 2:STE 115
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1331
Practice Address - Country:US
Practice Address - Phone:214-984-3900
Practice Address - Fax:972-294-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty