MEDICARE: PEDIATRIC NEURODEVELOPMENTAL ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629702717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC NEURODEVELOPMENTAL ASSOCIATES

Provider Business Mailing Address
First Line	:	3282 TOSCANA DR
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34772-6710
Country	:	US
Telephone Number	:	813-450-6128
Fax Number	:

Provider Business Practice Location Address
First Line	:	3282 TOSCANA DR
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34772-6710
Country	:	US
Telephone Number	:	813-450-6128
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. AVI ELIZABETH DOMNITZ-GEBET
Credential	:	DO
Telephone Number	:	813-450-6128

Provider Enumeration Date	:	07/13/2022
Last Update Date	:	07/25/2022

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