=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881162287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE CHILDREN'S CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2018
-----------------------------------------------------
Last Update Date | 05/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 N ALLEN DR
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-623-8218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 N ALLEN DR
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75013-2539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. SONAL JAIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 972-623-8218
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------