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General NPI Number Information
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NPI Number | 1093955940
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Entity Type | Organization
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Legal Business Name | LEE VISTA PEDIATRICS
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Dates
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Enumeration Date | 03/04/2009
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Last Update Date | 03/04/2009
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Provider Practice Location Address
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Address Line | 815 WOODBURY RD SUITE 102
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City | ORLANDO
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State | FL
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Zip | 32828-4515
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Country | US
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Telephone | 407-208-9870
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Fax | 407-208-9868
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Provider Business Mailing Address
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Address Line | 815 WOODBURY RD SUITE 102
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City | ORLANDO
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State | FL
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Zip | 32828-4515
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Country | US
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Telephone | 407-208-9870
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Fax | 407-208-9868
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARCIA GAYOSO
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Credential | MD
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Telephone | 407-208-9870
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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 | ME0084749
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License Number State | FL
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