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General NPI Number Information
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NPI Number | 1992730550
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Entity Type | Organization
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Legal Business Name | PROGRESSIVE PEDIATRICS OF ORLANDO PA
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 05/14/2008
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Provider Practice Location Address
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Address Line | 521 W STATE ROAD 434 SUITE 101
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City | LONGWOOD
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State | FL
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Zip | 32750
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Country | US
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Telephone | 407-830-5437
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Fax | 407-834-4907
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Provider Business Mailing Address
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Address Line | PO BOX 520879
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City | LONGWOOD
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State | FL
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Zip | 32752-0879
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Country | US
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Telephone | 407-830-5437
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Fax | 407-834-4907
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Authorized Official
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Title or Position | OWNER
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Name | ALFONSO MIRELES
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Credential | MD
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Telephone | 407-830-5437
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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 | ME54968
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License Number State | FL
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