Healthcare Provider Details

I. General information

NPI: 1548286552
Provider Name (Legal Business Name): ABC PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 COLLEGE BLVD W SUITE B
NICEVILLE FL
32578-1053
US

IV. Provider business mailing address

1005 COLLEGE BLVD W SUITE B
NICEVILLE FL
32578-1053
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-0900
  • Fax:
Mailing address:
  • Phone: 850-689-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME56157
License Number StateFL

VIII. Authorized Official

Name: LELA JOHNSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 850-689-0900