Basic Information
| Provider Information | |||||||||
| NPI: | 1043551591 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND PRAIRIE PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 NE 13TH ST | ||||||||
| Address2: | ORI 274 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731171039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052711515 | ||||||||
| FaxNumber: | 4052711001 | ||||||||
| Practice Location | |||||||||
| Address1: | 7301 N COMANCHE AVE | ||||||||
| Address2: | |||||||||
| City: | WARR ACRES | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731326646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057218090 | ||||||||
| FaxNumber: | 4057228529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2013 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | ZUBIALDE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DEAN | ||||||||
| AuthorizedOfficialTelephone: | 4052711515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA-OU PHYSICIANS | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.