Healthcare Provider Details

I. General information

NPI: 1922095512
Provider Name (Legal Business Name): SANTA ROSA PEDIATRICS OF FLORIDA P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5962 BERRYHILL RD
MILTON FL
32570-4009
US

IV. Provider business mailing address

5962 BERRYHILL RD
MILTON FL
32570-4009
US

V. Phone/Fax

Practice location:
  • Phone: 850-983-3700
  • Fax: 850-983-0970
Mailing address:
  • Phone: 850-983-3700
  • Fax: 850-983-0970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME90770
License Number StateFL

VIII. Authorized Official

Name: DR. LUIS A GHIGLINO
Title or Position: OWNER
Credential: MD
Phone: 850-983-3700