Healthcare Provider Details

I. General information

NPI: 1205763158
Provider Name (Legal Business Name): DAVENPORT PEDIATRICS P D
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 SW 5TH CT APT 1
DANIA BEACH FL
33004-3589
US

IV. Provider business mailing address

113 SW 5TH CT, APT 1
DANIA BEACH FL
33004-3589
US

V. Phone/Fax

Practice location:
  • Phone: 270-807-8431
  • Fax:
Mailing address:
  • Phone: 270-807-8431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MIN SOO JANG
Title or Position: OFFICE MANAGER
Credential:
Phone: 270-807-8431