Provider Demographics
NPI:1932529542
Name:DONIPHAN PEDIATRICS PA
Entity Type:Organization
Organization Name:DONIPHAN PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:BREA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-478-4847
Mailing Address - Street 1:6621 DONIPHAN DR
Mailing Address - Street 2:SPACE D
Mailing Address - City:CANUTILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79835-5002
Mailing Address - Country:US
Mailing Address - Phone:915-478-4847
Mailing Address - Fax:915-577-9143
Practice Address - Street 1:6621 DONIPHAN DR
Practice Address - Street 2:SPACE D
Practice Address - City:CANUTILLO
Practice Address - State:TX
Practice Address - Zip Code:79835-5002
Practice Address - Country:US
Practice Address - Phone:915-478-4847
Practice Address - Fax:915-577-9143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty