Healthcare Provider Details

I. General information

NPI: 1205863131
Provider Name (Legal Business Name): CONNIE PROSKOVEC DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11715 ORPINGTON ST STE A TLC PEDIATRIC AND ADOLESCENT MEDICINE IN ASSOC WITH NEM
ORLANDO FL
32817-4600
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPARTMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 407-380-9115
  • Fax: 302-651-4945
Mailing address:
  • Phone: 904-697-4203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3212
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS12811
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: