Healthcare Provider Details

I. General information

NPI: 1508002072
Provider Name (Legal Business Name): PEDIATRIC ENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2009
Last Update Date: 04/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 S HARBOR CITY BLVD STE 303
MELBOURNE FL
32901-3245
US

IV. Provider business mailing address

1499 S HARBOR CITY BLVD STE 303
MELBOURNE FL
32901-3245
US

V. Phone/Fax

Practice location:
  • Phone: 321-254-5437
  • Fax: 321-254-4543
Mailing address:
  • Phone: 321-254-5437
  • Fax: 321-254-4543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberME90348
License Number StateFL

VIII. Authorized Official

Name: DR. DAVID JOEL MALIS
Title or Position: MANAGER
Credential: MD
Phone: 321-254-5437