Provider Demographics
NPI:1952368664
Name:GRAND PRAIRIE PEDIATRIC AND ALLERGY CLINIC INC
Entity Type:Organization
Organization Name:GRAND PRAIRIE PEDIATRIC AND ALLERGY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-721-8090
Mailing Address - Street 1:7301 N COMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132
Mailing Address - Country:US
Mailing Address - Phone:405-721-8090
Mailing Address - Fax:405-722-8529
Practice Address - Street 1:7301 N COMANCHE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132
Practice Address - Country:US
Practice Address - Phone:405-721-8090
Practice Address - Fax:405-722-8529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11030208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E28930Medicare UPIN