Provider Demographics
NPI:1508071374
Name:PM PEDIATRICS PA
Entity Type:Organization
Organization Name:PM PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AZIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:IMTIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-483-0672
Mailing Address - Street 1:1412 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4051
Mailing Address - Country:US
Mailing Address - Phone:407-483-0672
Mailing Address - Fax:407-348-5882
Practice Address - Street 1:1412 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4051
Practice Address - Country:US
Practice Address - Phone:407-483-0672
Practice Address - Fax:407-348-5882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94323208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274223300Medicaid