Healthcare Provider Details

I. General information

NPI: 1447505961
Provider Name (Legal Business Name): KID MD PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13848 TILDEN RD SUITE 230
WINTER GARDEN FL
34787-5326
US

IV. Provider business mailing address

13848 TILDEN RD SUITE 230
WINTER GARDEN FL
34787-5326
US

V. Phone/Fax

Practice location:
  • Phone: 407-347-6144
  • Fax:
Mailing address:
  • Phone: 407-347-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME89366
License Number StateFL

VIII. Authorized Official

Name: RUBEN GONZALEZ-FLORIN
Title or Position: PRESIDENT
Credential: MD
Phone: 407-347-6144