Provider Demographics
NPI:1669928883
Name:NORTHSIDE PEDIATRICS ASSOCIATES, PA
Entity type:Organization
Organization Name:NORTHSIDE PEDIATRICS ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:OKOGBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-626-3808
Mailing Address - Street 1:15210 I-45 S
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77384-4105
Mailing Address - Country:US
Mailing Address - Phone:936-270-8655
Mailing Address - Fax:936-270-8739
Practice Address - Street 1:15210 I-45 SOUTH
Practice Address - Street 2:SUITE 110
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384-4105
Practice Address - Country:US
Practice Address - Phone:936-270-8655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4516208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1043224132OtherNPI
TX1609104785OtherNPI