Healthcare Provider Details

I. General information

NPI: 1679604904
Provider Name (Legal Business Name): FLORIDA PEDIATRIC GASTROENTEROLOGY GROUP, P.L.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9980 N. CENTRAL PARK BLVD. SUITE 202
BOCA RATON FL
33428
US

IV. Provider business mailing address

9980 N. CENTRAL PARK BLVD. SUITE 202
BOCA RATON FL
33428
US

V. Phone/Fax

Practice location:
  • Phone: 561-482-7038
  • Fax:
Mailing address:
  • Phone: 561-482-7038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LUIS OLIVA
Title or Position: FOUNDING MEMBER
Credential: M.D.
Phone: 561-482-2092