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General NPI Number Information
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NPI Number | 1821340472
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Entity Type | Organization
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Legal Business Name | FAIRWAY PEDIATRICS, PLLC
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Dates
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Enumeration Date | 10/06/2012
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Last Update Date | 01/07/2013
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Provider Practice Location Address
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Address Line | 4100 FAIRWAY DR SUITE 300
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City | CARROLLTON
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State | TX
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Zip | 75010-6525
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Country | US
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Telephone | 972-492-8880
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Fax | 972-492-8818
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Provider Business Mailing Address
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Address Line | 4100 FAIRWAY DR SUITE 300
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City | CARROLLTON
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State | TX
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Zip | 75010-6525
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Country | US
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Telephone | 972-492-8880
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Fax | 972-492-8818
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Authorized Official
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Title or Position | OWNER
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Name | JIAN WANG
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Credential | MD
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Telephone | 469-855-2073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | K6737
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License Number State | TX
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