Provider Demographics
NPI:1629702717
Name:PEDIATRIC NEURODEVELOPMENTAL ASSOCIATES
Entity Type:Organization
Organization Name:PEDIATRIC NEURODEVELOPMENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AVI
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:DOMNITZ-GEBET
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-450-6128
Mailing Address - Street 1:3282 TOSCANA DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-6710
Mailing Address - Country:US
Mailing Address - Phone:813-450-6128
Mailing Address - Fax:
Practice Address - Street 1:3282 TOSCANA DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-6710
Practice Address - Country:US
Practice Address - Phone:813-450-6128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty