Provider Demographics
NPI:1962685057
Name:KINGSVILLE PEDIATRIC CLINIC
Entity type:Organization
Organization Name:KINGSVILLE PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANDAYA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:361-595-5526
Mailing Address - Street 1:1311 GENERAL CAVAZOS BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78363-7129
Mailing Address - Country:US
Mailing Address - Phone:361-595-5526
Mailing Address - Fax:361-595-1050
Practice Address - Street 1:1311 GENERAL CAVAZOS BLVD STE J
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78363-7129
Practice Address - Country:US
Practice Address - Phone:361-595-5526
Practice Address - Fax:361-595-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4694174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty