MEDICARE: NEO2TEEN PEDIATRIC CLINIC, PA

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	208000000X	Pediatrics Physician	P2438	TX

General Provider Information

NPI Number	:	1770023624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEO2TEEN PEDIATRIC CLINIC, PA

Provider Business Mailing Address
First Line	:	23723 SUNSET PEAK
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-7544
Country	:	US
Telephone Number	:	210-888-9960
Fax Number	:	210-888-9422

Provider Business Practice Location Address
First Line	:	6735 FM 78
Second Line	:	SUITE 103
City	:	SAN ANTONIO
State	:	TX
Zip	:	78244-1367
Country	:	US
Telephone Number	:	210-888-9960
Fax Number	:	210-888-9422

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KENNETH ETOKHANA
Credential	:	MD
Telephone Number	:	210-888-9960

Provider Enumeration Date	:	02/26/2017
Last Update Date	:	04/27/2017

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