Healthcare Provider Details

I. General information

NPI: 1073695441
Provider Name (Legal Business Name): PHARR PEDIATRIC CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E POLK AVE
PHARR TX
78577-3110
US

IV. Provider business mailing address

105 E POLK AVE
PHARR TX
78577-3110
US

V. Phone/Fax

Practice location:
  • Phone: 956-781-6591
  • Fax: 956-702-0185
Mailing address:
  • Phone: 956-781-6591
  • Fax: 956-702-0185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberJ2456
License Number StateTX

VIII. Authorized Official

Name: ISRAEL MATA
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 956-781-6591