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General NPI Number Information
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NPI Number | 1023368164
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Entity Type | Organization
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Legal Business Name | PRIME PEDIATRIC ASSOCIATES, LLC
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Dates
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Enumeration Date | 09/17/2012
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Last Update Date | 09/17/2012
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Provider Practice Location Address
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Address Line | 100 E SAMPLE RD STE 120
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City | POMPANO BEACH
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State | FL
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Zip | 33064-3554
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Country | US
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Telephone | 954-941-2021
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Fax | 954-941-2071
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Provider Business Mailing Address
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Address Line | 100 E SAMPLE RD STE 120
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City | POMPANO BEACH
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State | FL
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Zip | 33064-3554
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Country | US
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Telephone | 954-941-2021
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Fax | 954-941-2071
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Authorized Official
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Title or Position | MGRM
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Name | DIBANNI VASQUEZ
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Credential | M.D.
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Telephone | 305-972-1073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME109534
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License Number State | FL
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