Healthcare Provider Details

I. General information

NPI: 1053793190
Provider Name (Legal Business Name): LAKEMONT PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 N LAKEMONT AVE
WINTER PARK FL
32792-3214
US

IV. Provider business mailing address

157 N LAKEMONT AVE
WINTER PARK FL
32792-3214
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-6618
  • Fax: 407-644-3755
Mailing address:
  • Phone: 407-644-6618
  • Fax: 407-644-3755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME100800
License Number StateFL

VIII. Authorized Official

Name: DR. VIVIEN D PHAM
Title or Position: MANAGER/PHYSICIAN
Credential: M.D.
Phone: 407-644-6618