Organization
KIDSVILLE PEDIATRICS SOUTHLAKE PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ALI SHAH (EXECUTIVE MANAGER)
(682) 345-8010
Entity
Organization
Contact information
Practice address
2813 W SOUTHLAKE BLVD STE 100, SOUTHLAKE, TX 76092-6832
(682) 345-8010
Mailing address
2813 W SOUTHLAKE BLVD STE 100, SOUTHLAKE, TX 76092-6832
(682) 345-8010
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
—
—
2080P0203X
Pediatric Critical Care Medicine Physician
Primary
—
—
2278P1006X
Pulmonary Function Technologist Certified Respiratory Therapist
—
—
363A00000X
Physician Assistant
—
—
363LP0200X
Pediatric Nurse Practitioner
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Enumeration date
10/01/2025
Last updated
10/02/2025
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