Provider Demographics
NPI:1417494873
Name:KIDZ PEDIATRIC MULTISPECIALTY
Entity Type:Organization
Organization Name:KIDZ PEDIATRIC MULTISPECIALTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:NAVARRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-661-1515
Mailing Address - Street 1:5955 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2423
Mailing Address - Country:US
Mailing Address - Phone:305-661-1515
Mailing Address - Fax:305-663-5948
Practice Address - Street 1:14421 METROPOLIS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4323
Practice Address - Country:US
Practice Address - Phone:239-597-7000
Practice Address - Fax:239-552-4060
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDZ MEDICAL SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 10324207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Multi-Specialty