Provider Demographics
NPI:1447301379
Name:PGVPEDIATRICS, PA
Entity type:Organization
Organization Name:PGVPEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANURADHA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGRAWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-823-2552
Mailing Address - Street 1:3310 LIVE OAK ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-6153
Mailing Address - Country:US
Mailing Address - Phone:214-823-2552
Mailing Address - Fax:
Practice Address - Street 1:3310 LIVE OAK ST
Practice Address - Street 2:SUITE 201
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6153
Practice Address - Country:US
Practice Address - Phone:214-823-2552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7295208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL7295OtherMEDICAL LICENSE