Healthcare Provider Details

I. General information

NPI: 1720761075
Provider Name (Legal Business Name): SOUTHEAST TEXAS PEDIATRIC CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 HIGHWAY 365 STE 107
NEDERLAND TX
77627-6268
US

IV. Provider business mailing address

2400 HIGHWAY 365 STE 107
NEDERLAND TX
77627-6268
US

V. Phone/Fax

Practice location:
  • Phone: 409-729-9200
  • Fax: 409-729-9235
Mailing address:
  • Phone: 409-729-9200
  • Fax: 409-729-9235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERTO MAYOR
Title or Position: ADMINISTRATOR
Credential:
Phone: 409-729-9200