Healthcare Provider Details

I. General information

NPI: 1902084064
Provider Name (Legal Business Name): PORT ORANGE PEDIATRICS P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 DUNLAWTON AVE SUITE 1
PORT ORANGE FL
32127-2915
US

IV. Provider business mailing address

1728 DUNLAWTON AVE STE 1
PORT ORANGE FL
32127-2923
US

V. Phone/Fax

Practice location:
  • Phone: 386-322-5390
  • Fax:
Mailing address:
  • Phone: 386-322-5390
  • Fax: 386-322-5391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0068668
License Number StateFL

VIII. Authorized Official

Name: RUBEN J LOPEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 386-322-5390