Healthcare Provider Details

I. General information

NPI: 1508826355
Provider Name (Legal Business Name): NATURE COAST PEDIATRICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 N LECANTO HWY
LECANTO FL
34461-8547
US

IV. Provider business mailing address

512 N LECANTO HWY
LECANTO FL
34461-8547
US

V. Phone/Fax

Practice location:
  • Phone: 352-527-2244
  • Fax: 352-527-2204
Mailing address:
  • Phone: 352-527-2244
  • Fax: 352-527-2204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME68580
License Number StateFL

VIII. Authorized Official

Name: KOMALA N BHUSHAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 352-527-2244