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General NPI Number Information
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NPI Number | 1841289204
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL PARK PEDIATRICS P.A.
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Dates
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Enumeration Date | 10/18/2005
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Last Update Date | 09/09/2009
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Provider Practice Location Address
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Address Line | 1881 PROFESSIONAL PARK CIR SUITE 80
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City | TALLAHASSEE
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State | FL
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Zip | 32308-4541
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Country | US
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Telephone | 850-402-5454
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Fax | 850-402-5451
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Provider Business Mailing Address
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Address Line | 1881 PROFESSIONAL PARK CIR SUITE 80
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City | TALLAHASSEE
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State | FL
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Zip | 32308-4541
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Country | US
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Telephone | 850-402-5454
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Fax | 850-402-5451
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WALTER G. BUNNELL III
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Credential | M.D.
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Telephone | 850-402-5454
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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 | ME91797
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME37597
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME75773
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME82183
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License Number State | FL
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