Provider Demographics
NPI:1083622633
Name:MY CHILDREN'S DOCTOR
Entity Type:Organization
Organization Name:MY CHILDREN'S DOCTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-625-1999
Mailing Address - Street 1:2484 CARING WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5306
Mailing Address - Country:US
Mailing Address - Phone:941-625-1999
Mailing Address - Fax:941-625-4600
Practice Address - Street 1:2484 CARING WAY
Practice Address - Street 2:SUITE D
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6729
Practice Address - Country:US
Practice Address - Phone:941-625-1999
Practice Address - Fax:941-625-4600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62983208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269202300Medicaid
FL269202300Medicaid