Healthcare Provider Details

I. General information

NPI: 1023368164
Provider Name (Legal Business Name): PRIME PEDIATRIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E SAMPLE RD STE 120
POMPANO BEACH FL
33064-3554
US

IV. Provider business mailing address

100 E SAMPLE RD STE 120
POMPANO BEACH FL
33064-3554
US

V. Phone/Fax

Practice location:
  • Phone: 954-941-2021
  • Fax: 954-941-2071
Mailing address:
  • Phone: 954-941-2021
  • Fax: 954-941-2071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME109534
License Number StateFL

VIII. Authorized Official

Name: DIBANNI VASQUEZ
Title or Position: MGRM
Credential: M.D.
Phone: 305-972-1073