Provider Demographics
NPI:1144292756
Name:KIDSVILLE PEDIATRICS II, P.A.
Entity type:Organization
Organization Name:KIDSVILLE PEDIATRICS II, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:PANTOJA JR.
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-518-0078
Mailing Address - Street 1:1050 W CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-1268
Mailing Address - Country:US
Mailing Address - Phone:407-518-0078
Mailing Address - Fax:407-518-0094
Practice Address - Street 1:1050 W CARROLL ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-1268
Practice Address - Country:US
Practice Address - Phone:407-518-0078
Practice Address - Fax:407-518-0094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-0074421208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274049400Medicaid
FL274049400Medicaid