Healthcare Provider Details

I. General information

NPI: 1376617043
Provider Name (Legal Business Name): BLOOMINGDALE PEDIATRIC ASS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 BELL SHOALS RD
VALRICO FL
33594
US

IV. Provider business mailing address

4316 BELL SHOALS RD
VALRICO FL
33594
US

V. Phone/Fax

Practice location:
  • Phone: 813-684-1881
  • Fax: 813-685-0471
Mailing address:
  • Phone: 813-684-1881
  • Fax: 813-685-0471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME45712
License Number StateFL

VIII. Authorized Official

Name: SONIA M RUIZ
Title or Position: PEDIATRICIAN
Credential: MD
Phone: 813-684-1881