Healthcare Provider Details

I. General information

NPI: 1609825694
Provider Name (Legal Business Name): ATLANTIC COAST PEDIATRICS, M.D. P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 N SYKES CREEK PKWY UNIT 108
MERRITT ISLAND FL
32953
US

IV. Provider business mailing address

PO BOX 541216
MERRITT ISLAND FL
32954-1216
US

V. Phone/Fax

Practice location:
  • Phone: 321-452-1061
  • Fax: 321-453-0866
Mailing address:
  • Phone: 321-452-1061
  • Fax: 321-453-0866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. LUIS A GONZALEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 321-452-1061