Healthcare Provider Details

I. General information

NPI: 1952727109
Provider Name (Legal Business Name): FIREFLY PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2148 JACKSON KELLER RD
SAN ANTONIO TX
78213-2722
US

IV. Provider business mailing address

2148 JACKSON KELLER RD
SAN ANTONIO TX
78213-2722
US

V. Phone/Fax

Practice location:
  • Phone: 210-501-0703
  • Fax: 210-526-0334
Mailing address:
  • Phone: 210-501-0703
  • Fax: 210-526-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberP3769
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP3769
License Number StateTX

VIII. Authorized Official

Name: MICHAEL LEE SEGURA
Title or Position: ADMINISTRATOR
Credential: MBA
Phone: 512-940-1027