=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063433076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTLAND PEDIATRICS OF LAKE WALES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1356 STATE ROAD 60 E ORANGE GROVE PLAZA
-----------------------------------------------------
City | LAKE WALES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33853-4322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-679-8888
-----------------------------------------------------
Fax | 863-676-2851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1356 STATE ROAD 60 E ORANGE GROVE PLAZA
-----------------------------------------------------
City | LAKE WALES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33853-4322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-679-8888
-----------------------------------------------------
Fax | 863-676-2851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. RAJESWARI SONNI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 863-679-8888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------