Provider Demographics
NPI:1972562957
Name:PAGAN, CARMEN JUDITH (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:JUDITH
Last Name:PAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:5270 BABCOCK ST NE STE 1
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905
Practice Address - Country:US
Practice Address - Phone:321-676-5996
Practice Address - Fax:321-676-5926
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82615208000000X
TXN3223208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100210500Medicaid
FL268228100Medicaid