Healthcare Provider Details

I. General information

NPI: 1659380459
Provider Name (Legal Business Name): NEW INTERLACHEN PEDIATRICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

846 LAKE HOWELL RD
MAITLAND FL
32751-5222
US

IV. Provider business mailing address

846 LAKE HOWELL RD
MAITLAND FL
32751-5222
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-2477
  • Fax: 407-834-9822
Mailing address:
  • Phone: 407-767-2477
  • Fax: 407-834-9822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. LUIS SALAZAR
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 407-767-2477