Provider Demographics
NPI:1326418336
Name:ABC PEDIATRICS OF OKALOOSA
Entity Type:Organization
Organization Name:ABC PEDIATRICS OF OKALOOSA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-689-0900
Mailing Address - Street 1:2260 S FERDON BLVD
Mailing Address - Street 2:BOX 92
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-8457
Mailing Address - Country:US
Mailing Address - Phone:850-689-0900
Mailing Address - Fax:850-689-0912
Practice Address - Street 1:182 E. REDSTONE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539
Practice Address - Country:US
Practice Address - Phone:850-689-0900
Practice Address - Fax:850-689-0912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME708312080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250009400Medicaid