Provider Demographics
NPI:1699812552
Name:DECATUR LITTLE EAGLE PEDIATRICS, P.A.
Entity type:Organization
Organization Name:DECATUR LITTLE EAGLE PEDIATRICS, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-627-8044
Mailing Address - Street 1:2401 S FM 51
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3781
Mailing Address - Country:US
Mailing Address - Phone:940-627-8044
Mailing Address - Fax:940-627-8055
Practice Address - Street 1:2401 S FM 51
Practice Address - Street 2:SUITE 100
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3781
Practice Address - Country:US
Practice Address - Phone:940-627-8044
Practice Address - Fax:940-627-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2797208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4196310OtherBLUE LINK
TXTHS # 171105302Medicaid
TX171105301Medicaid
TX171105301Medicaid