Healthcare Provider Details

I. General information

NPI: 1376676403
Provider Name (Legal Business Name): THE WEST COVINA KIDS DOC ,APMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 S SUNSET AVE SUITE # 101
WEST COVINA CA
91790-3410
US

IV. Provider business mailing address

PO BOX 4219
WEST COVINA CA
91791-0219
US

V. Phone/Fax

Practice location:
  • Phone: 626-919-5437
  • Fax: 626-919-5439
Mailing address:
  • Phone: 626-919-5437
  • Fax: 626-919-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PANKAJ N MISTRY
Title or Position: PRESIDENT,CEO
Credential: MD
Phone: 626-919-5437