Provider Demographics
NPI:1265005565
Name:SUMTER PEDIATRICS PA
Entity Type:Organization
Organization Name:SUMTER PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:AFZAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-394-3929
Mailing Address - Street 1:617 S US 301 STE B
Mailing Address - Street 2:
Mailing Address - City:SUMTERVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:33585-5355
Mailing Address - Country:US
Mailing Address - Phone:352-569-4980
Mailing Address - Fax:
Practice Address - Street 1:617 S US 301 STE B
Practice Address - Street 2:
Practice Address - City:SUMTERVILLE
Practice Address - State:FL
Practice Address - Zip Code:33585-5355
Practice Address - Country:US
Practice Address - Phone:352-569-4980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014683501Medicaid