Healthcare Provider Details

I. General information

NPI: 1932728995
Provider Name (Legal Business Name): ALL AGES PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 HOSPITAL DR
BONIFAY FL
32425-4268
US

IV. Provider business mailing address

2717 TALON CT
PANAMA CITY FL
32405-6672
US

V. Phone/Fax

Practice location:
  • Phone: 850-547-8158
  • Fax: 850-547-8090
Mailing address:
  • Phone: 407-496-8095
  • Fax: 850-547-8090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KHALED AL-FARAWI
Title or Position: OWNER
Credential: MD
Phone: 407-496-8095