Healthcare Provider Details

I. General information

NPI: 1275109993
Provider Name (Legal Business Name): PEDIATRIC UNIVERSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 INNOVATION DR
SAINT CLOUD FL
34769-6501
US

IV. Provider business mailing address

11914 LORENZA LN
ORLANDO FL
32827-7800
US

V. Phone/Fax

Practice location:
  • Phone: 860-992-6794
  • Fax:
Mailing address:
  • Phone: 860-992-6794
  • Fax:

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. SAMIR DRAA
Title or Position: CEO/ MANAGER
Credential: MD
Phone: 860-992-6794