Basic Information
| Provider Information | |||||||||
| NPI: | 1104008598 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NICHOLAS PEREIRA MDPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5111 N 10TH ST | ||||||||
| Address2: | # 112 | ||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785042835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564512316 | ||||||||
| FaxNumber: | 9566316717 | ||||||||
| Practice Location | |||||||||
| Address1: | 5111 N 10TH ST | ||||||||
| Address2: | # 112 | ||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785042835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564512316 | ||||||||
| FaxNumber: | 9566316717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | PEREIRA | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9564512316 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | K3389 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 190654701 | 05 | TX | MEDICAID |