Provider Demographics
NPI:1992297816
Name:PAK MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:PAK MEDICAL GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HARLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:106-302-2072
Mailing Address - Street 1:425 W COLONIAL DR STE 303
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6863
Mailing Address - Country:US
Mailing Address - Phone:321-343-6833
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:1762 E COMMON ST
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-6059
Practice Address - Country:US
Practice Address - Phone:830-730-8580
Practice Address - Fax:830-327-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3947798-02Medicaid
TX3947798-01Medicaid