Healthcare Provider Details

I. General information

NPI: 1720603129
Provider Name (Legal Business Name): KIDS' CORNER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 BELL SHOALS ROAD
BRANDON FL
33511-8813
US

IV. Provider business mailing address

1114 BELL SHOALS RD
BRANDON FL
33511-8813
US

V. Phone/Fax

Practice location:
  • Phone: 813-940-8140
  • Fax: 813-940-8148
Mailing address:
  • Phone: 813-940-8140
  • Fax: 813-940-8148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: EVER I RIVERA
Title or Position: OWNER
Credential: MD
Phone: 813-940-8140