Provider Demographics
NPI:1205863131
Name:PROSKOVEC, CONNIE (DO)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:PROSKOVEC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:904-697-4203
Mailing Address - Fax:
Practice Address - Street 1:11715 ORPINGTON ST STE A
Practice Address - Street 2:TLC PEDIATRIC AND ADOLESCENT MEDICINE IN ASSOC WITH NEM
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4600
Practice Address - Country:US
Practice Address - Phone:407-380-9115
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3212208000000X
FLOS12811208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014367300Medicaid
OK100252200AMedicaid
FL014367300Medicaid