Provider Demographics
NPI:1609825694
Name:ATLANTIC COAST PEDIATRICS, M.D. P.A.
Entity Type:Organization
Organization Name:ATLANTIC COAST PEDIATRICS, M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-452-1061
Mailing Address - Street 1:PO BOX 541216
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32954-1216
Mailing Address - Country:US
Mailing Address - Phone:321-452-1061
Mailing Address - Fax:321-453-0866
Practice Address - Street 1:270 N SYKES CREEK PKWY
Practice Address - Street 2:UNIT 108
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953
Practice Address - Country:US
Practice Address - Phone:321-452-1061
Practice Address - Fax:321-453-0866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054902900Medicaid