Provider Demographics
NPI:1356470744
Name:ENGLEWOOD PEDIATRICS, P.A.
Entity Type:Organization
Organization Name:ENGLEWOOD PEDIATRICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GUASTAVINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-474-5093
Mailing Address - Street 1:900 PINE ST UNIT 216-217
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-4418
Mailing Address - Country:US
Mailing Address - Phone:941-474-5093
Mailing Address - Fax:941-474-9049
Practice Address - Street 1:900 PINE ST UNIT 216-217
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-4418
Practice Address - Country:US
Practice Address - Phone:941-474-5093
Practice Address - Fax:941-474-9049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-03
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0059964208000000X, 261QM0855X
FL800002855291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054195800Medicaid