Provider Demographics
NPI:1093108326
Name:SUNSHINE STATE PEDIATRICS
Entity Type:Organization
Organization Name:SUNSHINE STATE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-655-2340
Mailing Address - Street 1:16800 NW 2ND AVE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5549
Mailing Address - Country:US
Mailing Address - Phone:305-655-2340
Mailing Address - Fax:305-770-9382
Practice Address - Street 1:16800 NW 2ND AVENUE
Practice Address - Street 2:SUITE 307
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169
Practice Address - Country:US
Practice Address - Phone:305-655-2340
Practice Address - Fax:305-770-9382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58963261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care