Healthcare Provider Details

I. General information

NPI: 1861361115
Provider Name (Legal Business Name): PEDIATRIC GASTROENTEROLOGY ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10045 S DIXIE HWY
PINECREST FL
33156-3145
US

IV. Provider business mailing address

10045 S DIXIE HWY
PINECREST FL
33156-3145
US

V. Phone/Fax

Practice location:
  • Phone: 786-888-2480
  • Fax:
Mailing address:
  • Phone: 786-888-2480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: JESSE REEVES GARCIA
Title or Position: MD/OWNER
Credential: MD
Phone: 786-888-2480