Healthcare Provider Details

I. General information

NPI: 1699076901
Provider Name (Legal Business Name): SOUTH LAKE PEDIATRICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3155 CITRUS TOWER BLVD BLDG.# 1
CLERMONT FL
34711-6803
US

IV. Provider business mailing address

3155 CITRUS TOWER BLVD BLDG.# 1
CLERMONT FL
34711-6803
US

V. Phone/Fax

Practice location:
  • Phone: 352-242-1500
  • Fax: 352-242-0053
Mailing address:
  • Phone: 352-242-1500
  • Fax: 352-242-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME073750
License Number StateFL

VIII. Authorized Official

Name: DR. ADINARAYANAMURTHY NALLAMSHETTY
Title or Position: PRESIDENT
Credential: MD
Phone: 352-242-1500