Provider Demographics
NPI:1619128675
Name:MY PEDIATRICIAN, P.A.
Entity Type:Organization
Organization Name:MY PEDIATRICIAN, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:MEDRANO
Authorized Official - Last Name:ONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-684-5659
Mailing Address - Street 1:1037 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4886
Mailing Address - Country:US
Mailing Address - Phone:813-684-5659
Mailing Address - Fax:
Practice Address - Street 1:1037 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4886
Practice Address - Country:US
Practice Address - Phone:813-684-5659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78831208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty