Provider Demographics
NPI:1750913117
Name:WONDER KIDS SPECIALTY PEDIATRICS PLLC
Entity type:Organization
Organization Name:WONDER KIDS SPECIALTY PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-713-2947
Mailing Address - Street 1:4202 SW LEE BLVD
Mailing Address - Street 2:BUILDING B, SUITE 100
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-8343
Mailing Address - Country:US
Mailing Address - Phone:580-368-0808
Mailing Address - Fax:
Practice Address - Street 1:5606 SW LEE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9651
Practice Address - Country:US
Practice Address - Phone:580-368-0808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-04
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty