=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942547609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC ASSOCIATES OF CONVERSE, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2013
-----------------------------------------------------
Last Update Date | 01/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9135 SCHAEFER RD STE 4
-----------------------------------------------------
City | CONVERSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78109-1979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-281-5507
-----------------------------------------------------
Fax | 210-290-9791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9135 SCHAEFER RD STE 4
-----------------------------------------------------
City | CONVERSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78109-1979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-281-5507
-----------------------------------------------------
Fax | 210-290-9791
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | SUBHASHINI S VALAVALKAR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 210-281-5507
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number | N7595
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------