MEDICARE: LAKE LEWISVILLE PEDIATRICS, LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1649471814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE LEWISVILLE PEDIATRICS, LLP

Provider Business Mailing Address
First Line	:	2141 S EDMONDS LN
Second Line	:
City	:	LEWISVILLE
State	:	TX
Zip	:	75067-6162
Country	:	US
Telephone Number	:	972-315-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2141 S EDMONDS LN
Second Line	:
City	:	LEWISVILLE
State	:	TX
Zip	:	75067-6162
Country	:	US
Telephone Number	:	972-315-8500
Fax Number	:

Authorized Official
Title or Position	:	MD
Name	:	JOHN GLEN OGDEN
Credential	:
Telephone Number	:	972-315-8500

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	08/22/2020

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