MEDICARE: MY PEDIATRICIAN, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME78831	FL

General Provider Information

NPI Number	:	1619128675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY PEDIATRICIAN, P.A.

Provider Business Mailing Address
First Line	:	1037 PROFESSIONAL PARK DR
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-4886
Country	:	US
Telephone Number	:	813-684-5659
Fax Number	:

Provider Business Practice Location Address
First Line	:	1037 PROFESSIONAL PARK DR
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-4886
Country	:	US
Telephone Number	:	813-684-5659
Fax Number	:

Authorized Official
Title or Position	:	PEDIATRICIAN/OWNER
Name	:	ALICIA MEDRANO ONG
Credential	:	M.D.
Telephone Number	:	813-684-5659

Provider Enumeration Date	:	10/08/2008
Last Update Date	:	10/08/2008

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