Provider Demographics
NPI:1417129602
Name:PEDIATRIC NEUROLOGY PA
Entity Type:Organization
Organization Name:PEDIATRIC NEUROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-293-1122
Mailing Address - Street 1:1245 W FAIRBANKS AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4878
Mailing Address - Country:US
Mailing Address - Phone:407-293-1122
Mailing Address - Fax:407-253-2170
Practice Address - Street 1:7485 SANDLAKE COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8034
Practice Address - Country:US
Practice Address - Phone:407-293-1122
Practice Address - Fax:407-253-2170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME816622080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280885400Medicaid