Provider Demographics
NPI:1750676581
Name:KIDSVILLE PEDIATRICS VI, PA AFTER HOURS CLINIC
Entity Type:Organization
Organization Name:KIDSVILLE PEDIATRICS VI, PA AFTER HOURS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:PANTOJA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:407-447-7773
Mailing Address - Street 1:11886 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-4436
Mailing Address - Country:US
Mailing Address - Phone:407-447-7773
Mailing Address - Fax:407-447-7804
Practice Address - Street 1:11886 LAKE UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4436
Practice Address - Country:US
Practice Address - Phone:407-447-7773
Practice Address - Fax:407-447-7804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-09
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty