Basic Information
| Provider Information | |||||||||
| NPI: | 1508276668 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIND BODY PEDIATRIC CLINIC PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2686 WEST ALTON GLOOR, SUITE 2. | ||||||||
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| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563502844 | ||||||||
| FaxNumber: | 9563502493 | ||||||||
| Practice Location | |||||||||
| Address1: | 2686 WEST ALTON GLOOR, SUITE 2. | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563502844 | ||||||||
| FaxNumber: | 9563502493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2014 | ||||||||
| LastUpdateDate: | 04/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | AKRAM | ||||||||
| AuthorizedOfficialFirstName: | NOVERA | ||||||||
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| AuthorizedOfficialTitleorPosition: | M.D. | ||||||||
| AuthorizedOfficialTelephone: | 9563505444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | L9993 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.