Provider Demographics
NPI:1184854176
Name:SUNSHINE STATE PEDIATRICS OF CENTRAL FLORIDA INC
Entity Type:Organization
Organization Name:SUNSHINE STATE PEDIATRICS OF CENTRAL FLORIDA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:KOVACS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:407-977-1234
Mailing Address - Street 1:PO BOX 623747
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32762-3747
Mailing Address - Country:US
Mailing Address - Phone:407-977-1234
Mailing Address - Fax:407-977-1235
Practice Address - Street 1:8000 RED BUG LAKE RD STE 280
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9267
Practice Address - Country:US
Practice Address - Phone:407-977-1234
Practice Address - Fax:407-977-1235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL96797208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty