Healthcare Provider Details

I. General information

NPI: 1861928368
Provider Name (Legal Business Name): PEDIATRIC NEUROLOGY OF FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 SE 25TH LOOP UNIT 104
OCALA FL
34471-1030
US

IV. Provider business mailing address

1315 SE 25TH LOOP UNIT 104
OCALA FL
34471-1030
US

V. Phone/Fax

Practice location:
  • Phone: 352-260-7343
  • Fax:
Mailing address:
  • Phone: 352-260-7343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: EDGARD O ANDRADE
Title or Position: PRESIDENT
Credential: MD
Phone: 352-260-7346