Provider Demographics
NPI:1528390556
Name:FLORIDA CHILDREN'S CENTER OF GASTROENTEROLOGY, LLC
Entity Type:Organization
Organization Name:FLORIDA CHILDREN'S CENTER OF GASTROENTEROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KHUBCHANDANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-438-3557
Mailing Address - Street 1:6735 CONROY WINDERMERE RD
Mailing Address - Street 2:SUITE 226
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-3565
Mailing Address - Country:US
Mailing Address - Phone:407-438-3557
Mailing Address - Fax:407-438-3558
Practice Address - Street 1:6735 CONROY WINDERMERE RD
Practice Address - Street 2:SUITE 226
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-3565
Practice Address - Country:US
Practice Address - Phone:407-438-3557
Practice Address - Fax:407-438-3558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-01
Last Update Date:2014-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003522800Medicaid