=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750676581
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDSVILLE PEDIATRICS VI, PA AFTER HOURS CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2011
-----------------------------------------------------
Last Update Date | 08/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11886 LAKE UNDERHILL RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-4436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-447-7773
-----------------------------------------------------
Fax | 407-447-7804
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11886 LAKE UNDERHILL RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-4436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-447-7773
-----------------------------------------------------
Fax | 407-447-7804
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO/ADMINISTRATOR
-----------------------------------------------------
Name | MR. VICTOR MANUEL PANTOJA JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-447-7773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------