Provider Demographics
NPI:1285165332
Name:PEDICARE CHILDRENS URGENT CARE PA
Entity type:Organization
Organization Name:PEDICARE CHILDRENS URGENT CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KOLAWOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ODUMUSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-695-6300
Mailing Address - Street 1:PO BOX 60893
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-0893
Mailing Address - Country:US
Mailing Address - Phone:361-334-0613
Mailing Address - Fax:361-214-2983
Practice Address - Street 1:6326 YORKTOWN BLVD STE 1B
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-5861
Practice Address - Country:US
Practice Address - Phone:361-334-0613
Practice Address - Fax:361-334-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2022-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4362208000000X
TXQ5518208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid