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General NPI Number Information
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NPI Number | 1629702717
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Entity Type | Organization
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Legal Business Name | PEDIATRIC NEURODEVELOPMENTAL ASSOCIATES
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Dates
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Enumeration Date | 07/13/2022
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Last Update Date | 07/25/2022
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Provider Practice Location Address
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Address Line | 3282 TOSCANA DR
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City | SAINT CLOUD
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State | FL
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Zip | 34772-6710
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Country | US
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Telephone | 813-450-6128
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Fax |
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Provider Business Mailing Address
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Address Line | 3282 TOSCANA DR
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City | SAINT CLOUD
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State | FL
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Zip | 34772-6710
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Country | US
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Telephone | 813-450-6128
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. AVI ELIZABETH DOMNITZ-GEBET
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Credential | DO
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Telephone | 813-450-6128
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0402X
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Taxonomy Name | Neurology with Special Qualifications in Child Neurology Physician
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License Number |
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License Number State |
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