Provider Demographics
NPI:1245621127
Name:PRINCIPAL PEDIATRIC GROUP LLC
Entity type:Organization
Organization Name:PRINCIPAL PEDIATRIC GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AYODEJI
Authorized Official - Middle Name:B
Authorized Official - Last Name:OTEGBEYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-894-8768
Mailing Address - Street 1:844 N THORNTON AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4003
Mailing Address - Country:US
Mailing Address - Phone:407-894-8768
Mailing Address - Fax:407-894-6872
Practice Address - Street 1:5900 S JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-3716
Practice Address - Country:US
Practice Address - Phone:407-398-6470
Practice Address - Fax:407-894-6872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58278208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty