Provider Demographics
NPI:1477834380
Name:KIDZ DOC, PA
Entity Type:Organization
Organization Name:KIDZ DOC, PA
Other - Org Name:KIDZ DOC, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-668-2144
Mailing Address - Street 1:6080 SW 40TH ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-5233
Mailing Address - Country:US
Mailing Address - Phone:305-668-2144
Mailing Address - Fax:305-668-7791
Practice Address - Street 1:6080 SW 40TH ST
Practice Address - Street 2:SUITE 9
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-5233
Practice Address - Country:US
Practice Address - Phone:305-668-2144
Practice Address - Fax:305-668-7791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54056208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL062069600Medicaid