MEDICARE: KIDSVILLE PEDIATRICS PROSPER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	208000000X	Pediatrics Physician
2	2278P1006X	Pulmonary Function Technologist Certified Respiratory Therapist
3	363A00000X	Physician Assistant
4	363LP0200X	Pediatric Nurse Practitioner
5	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
6	2080P0203X	Pediatric Critical Care Medicine Physician

General Provider Information

NPI Number	:	1255292785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDSVILLE PEDIATRICS PROSPER

Provider Business Mailing Address
First Line	:	1400 N COIT RD STE 1604
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75071-6661
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 N COIT RD STE 1604
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75071-6661
Country	:	US
Telephone Number	:	682-868-1020
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE MANAGER
Name	:	ALI SHAH
Credential	:
Telephone Number	:	682-868-1020

Provider Enumeration Date	:	11/24/2025
Last Update Date	:	11/24/2025

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