Healthcare Provider Details

I. General information

NPI: 1245621127
Provider Name (Legal Business Name): PRINCIPAL PEDIATRIC GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 S JOHN YOUNG PKWY
ORLANDO FL
32839-3716
US

IV. Provider business mailing address

844 N THORNTON AVE
ORLANDO FL
32803-4003
US

V. Phone/Fax

Practice location:
  • Phone: 407-398-6470
  • Fax: 407-894-6872
Mailing address:
  • Phone: 407-894-8768
  • Fax: 407-894-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME58278
License Number StateFL

VIII. Authorized Official

Name: DR. AYODEJI B OTEGBEYE
Title or Position: PRESIDENT
Credential: MD
Phone: 407-894-8768