Healthcare Provider Details

I. General information

NPI: 1295766558
Provider Name (Legal Business Name): PEDIATRIC GASTROENTEROLOGY ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8955 SW 87TH CT STE 206
MIAMI FL
33176-2223
US

IV. Provider business mailing address

3200 SW 60TH CT STE 204
MIAMI FL
33155-4070
US

V. Phone/Fax

Practice location:
  • Phone: 786-888-2480
  • Fax:
Mailing address:
  • Phone: 305-661-6110
  • Fax: 305-662-5882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSE REEVES-GARCIA
Title or Position: PRESIDENT
Credential: MD
Phone: 305-661-6110