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General NPI Number Information
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NPI Number | 1508002072
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Entity Type | Organization
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Legal Business Name | PEDIATRIC ENT, LLC
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Dates
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Enumeration Date | 01/05/2009
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Last Update Date | 04/18/2014
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Provider Practice Location Address
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Address Line | 1499 S HARBOR CITY BLVD STE 303
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City | MELBOURNE
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State | FL
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Zip | 32901-3245
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Country | US
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Telephone | 321-254-5437
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Fax | 321-254-4543
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Provider Business Mailing Address
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Address Line | 1499 S HARBOR CITY BLVD STE 303
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City | MELBOURNE
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State | FL
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Zip | 32901-3245
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Country | US
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Telephone | 321-254-5437
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Fax | 321-254-4543
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Authorized Official
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Title or Position | MANAGER
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Name | DR. DAVID JOEL MALIS
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Credential | MD
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Telephone | 321-254-5437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YP0228X
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Taxonomy Name | Pediatric Otolaryngology Physician
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License Number | ME90348
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License Number State | FL
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