Healthcare Provider Details

I. General information

NPI: 1770731291
Provider Name (Legal Business Name): PALM BAY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 MALABAR RD
MALABAR FL
32950-3120
US

IV. Provider business mailing address

775 MALABAR RD
MALABAR FL
32950-3120
US

V. Phone/Fax

Practice location:
  • Phone: 321-722-8435
  • Fax: 321-722-8486
Mailing address:
  • Phone: 321-722-8435
  • Fax: 321-722-8486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME63747
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberME63747
License Number StateFL

VIII. Authorized Official

Name: DR. DORIS MARGARITA LEEDY
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 321-722-8435