Provider Demographics
NPI:1972679223
Name:PRO STAR PEDIATRICS
Entity Type:Organization
Organization Name:PRO STAR PEDIATRICS
Other - Org Name:RDV SPORTSPLEX PEDIATRICS
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:COBIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-916-4522
Mailing Address - Street 1:8701 MAITLAND SUMMIT BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-5915
Mailing Address - Country:US
Mailing Address - Phone:407-916-4522
Mailing Address - Fax:407-916-4525
Practice Address - Street 1:8701 MAITLAND SUMMIT BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-5915
Practice Address - Country:US
Practice Address - Phone:407-916-4522
Practice Address - Fax:407-916-4525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00365542080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269488300Medicaid
FL003657000Medicaid
FL041847101Medicaid
FL041847101Medicaid