Healthcare Provider Details

I. General information

NPI: 1518911569
Provider Name (Legal Business Name): FUNCOAST PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1688 W GRANADA BLVD SUITE 2B
ORMOND BEACH FL
32174
US

IV. Provider business mailing address

1688 W GRANADA BLVD SUITE 2B
ORMOND BEACH FL
32174
US

V. Phone/Fax

Practice location:
  • Phone: 386-677-3530
  • Fax: 386-673-1933
Mailing address:
  • Phone: 386-677-3530
  • Fax: 386-673-1933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JAMES GRADY WHITE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 386-677-3530