Healthcare Provider Details

I. General information

NPI: 1891850855
Provider Name (Legal Business Name): CRESTVIEW PEDIATRICS AND ADOLESCENT CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 MEDCREST DRIVE
CRESTVIEW FL
32536
US

IV. Provider business mailing address

332 MEDCREST DRIVE
CRESTVIEW FL
32536
US

V. Phone/Fax

Practice location:
  • Phone: 850-683-5100
  • Fax: 850-683-5102
Mailing address:
  • Phone: 850-683-5100
  • Fax: 850-683-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME74916
License Number StateFL

VIII. Authorized Official

Name: MRS. BERNADINE S PETER
Title or Position: OFFICE MGR
Credential:
Phone: 850-683-5100