Provider Demographics
NPI:1558403691
Name:DAVENPORT PEDIATRICS
Entity Type:Organization
Organization Name:DAVENPORT PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA CRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-421-1855
Mailing Address - Street 1:103 PARK PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-6858
Mailing Address - Country:US
Mailing Address - Phone:863-421-1855
Mailing Address - Fax:863-421-2624
Practice Address - Street 1:103 PARK PLACE BLVD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-6858
Practice Address - Country:US
Practice Address - Phone:863-421-1855
Practice Address - Fax:863-421-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275150000Medicaid