Provider Demographics
NPI:1770023624
Name:NEO2TEEN PEDIATRIC CLINIC, PA
Entity type:Organization
Organization Name:NEO2TEEN PEDIATRIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ETOKHANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-888-9960
Mailing Address - Street 1:23723 SUNSET PEAK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-7544
Mailing Address - Country:US
Mailing Address - Phone:210-888-9960
Mailing Address - Fax:210-888-9422
Practice Address - Street 1:6735 FM 78
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-1367
Practice Address - Country:US
Practice Address - Phone:210-888-9960
Practice Address - Fax:210-888-9422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-26
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2438208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty