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General NPI Number Information
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NPI Number | 1942463724
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Entity Type | Organization
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Legal Business Name | VILLAGE PEDIATRICS, PA
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Dates
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Enumeration Date | 07/02/2008
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Last Update Date | 07/02/2008
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Provider Practice Location Address
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Address Line | 998 WINSCOTT RD
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City | BENBROOK
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State | TX
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Zip | 76126-2744
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Country | US
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Telephone | 817-249-4155
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Fax | 817-249-0497
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Provider Business Mailing Address
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Address Line | 4917 RIVERBEND DR
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City | FORT WORTH
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State | TX
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Zip | 76109-2436
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Country | US
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Telephone | 817-249-4155
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Fax | 817-249-0497
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. STEPHANIE PERDUE
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Credential | MD
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Telephone | 817-249-4155
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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 | K0154
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License Number State | TX
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