Healthcare Provider Details

I. General information

NPI: 1861043259
Provider Name (Legal Business Name): PEDIATRIC DEPOT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1446 W MOORE AVE STE 206
TERRELL TX
75160-2372
US

IV. Provider business mailing address

1446 W MOORE AVE STE 206
TERRELL TX
75160-2372
US

V. Phone/Fax

Practice location:
  • Phone: 972-210-7350
  • Fax: 972-210-7355
Mailing address:
  • Phone: 972-210-7350
  • Fax: 972-210-7355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROSHNI PATEL
Title or Position: MANAGING MEMBER
Credential: NP
Phone: 972-210-7350