Healthcare Provider Details

I. General information

NPI: 1417129602
Provider Name (Legal Business Name): PEDIATRIC NEUROLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7485 SANDLAKE COMMONS BLVD
ORLANDO FL
32819-8034
US

IV. Provider business mailing address

1245 W FAIRBANKS AVE STE 305
WINTER PARK FL
32789-4878
US

V. Phone/Fax

Practice location:
  • Phone: 407-293-1122
  • Fax: 407-253-2170
Mailing address:
  • Phone: 407-293-1122
  • Fax: 407-253-2170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License NumberME81662
License Number StateFL

VIII. Authorized Official

Name: MR. EMMANUEL VEGA
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-293-1122