Provider Demographics
NPI:1740401736
Name:PEDIATRIC HEALTH OF WESTON, PA
Entity Type:Organization
Organization Name:PEDIATRIC HEALTH OF WESTON, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:954-659-0333
Mailing Address - Street 1:2233 N COMMERCE PKWY
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3252
Mailing Address - Country:US
Mailing Address - Phone:954-659-0333
Mailing Address - Fax:954-659-0999
Practice Address - Street 1:2233 N COMMERCE PKWY
Practice Address - Street 2:SUITE # 2
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3252
Practice Address - Country:US
Practice Address - Phone:954-659-0333
Practice Address - Fax:954-659-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073596208000000X
261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253480100Medicaid