Provider Demographics
NPI:1255489308
Name:GULF COAST PEDIATRICS OF SARASOTA, PA-C
Entity Type:Organization
Organization Name:GULF COAST PEDIATRICS OF SARASOTA, PA-C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-412-1515
Mailing Address - Street 1:5664 BEE RIDGE RD
Mailing Address - Street 2:STE. 202
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-1504
Mailing Address - Country:US
Mailing Address - Phone:941-377-6406
Mailing Address - Fax:941-377-6407
Practice Address - Street 1:405 COMMERCIAL CT STE D
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-1653
Practice Address - Country:US
Practice Address - Phone:941-412-1515
Practice Address - Fax:941-412-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268427601Medicaid