Provider Demographics
NPI:1619339264
Name:PEDIATRICIANS OF FLORIDA
Entity Type:Organization
Organization Name:PEDIATRICIANS OF FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICKEEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SALMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-225-1343
Mailing Address - Street 1:820 W LAKE MARY BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-5946
Mailing Address - Country:US
Mailing Address - Phone:407-955-4445
Mailing Address - Fax:
Practice Address - Street 1:820 W LAKE MARY BLVD
Practice Address - Street 2:STE 102
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-5946
Practice Address - Country:US
Practice Address - Phone:407-955-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99391208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014797700Medicaid