Healthcare Provider Details

I. General information

NPI: 1215901723
Provider Name (Legal Business Name): KIDSVILLE PEDIATRICS III, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 OAKLEY SEAVER BLVD SUITE-C
CLERMONT FL
34711-1925
US

IV. Provider business mailing address

1804 OAKLEY SEAVER BLVD SUITE-C
CLERMONT FL
34711-1925
US

V. Phone/Fax

Practice location:
  • Phone: 352-242-1021
  • Fax: 352-242-1104
Mailing address:
  • Phone: 352-242-1021
  • Fax: 352-242-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. VICTOR M. PANTOJA JR.
Title or Position: ADMINISTRATOR
Credential:
Phone: 352-242-1021