Healthcare Provider Details

I. General information

NPI: 1124190764
Provider Name (Legal Business Name): ISLAND PEDIATRICS OF ISLAMORADA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 03/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81599 OLD HWY
ISLAMORADA FL
33036-3711
US

IV. Provider business mailing address

81599 OLD HWY
ISLAMORADA FL
33036-3711
US

V. Phone/Fax

Practice location:
  • Phone: 305-664-3384
  • Fax:
Mailing address:
  • Phone: 305-664-3384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME103085
License Number StateFL

VIII. Authorized Official

Name: DR. KRISTI BENGTSON BAGNELL
Title or Position: PRESIDENT
Credential: MD
Phone: 305-664-3384