Basic Information
Provider Information | |||||||||
NPI: | 1619433034 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARIPOSA PERINATAL SERVICES PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9330 LBJ FWY STE 800 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752434310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9727925700 | ||||||||
FaxNumber: | 2145061170 | ||||||||
Practice Location | |||||||||
Address1: | 1510 W. HWY 287 BYPASS | ||||||||
Address2: | STE. 100 | ||||||||
City: | WAXAHACHIE | ||||||||
State: | TX | ||||||||
PostalCode: | 75165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729053778 | ||||||||
FaxNumber: | 8442135189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2019 | ||||||||
LastUpdateDate: | 10/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PREDANIC | ||||||||
AuthorizedOfficialFirstName: | MLADEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2145062617 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 10/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
No ID Information.