Provider Demographics
NPI:1669432134
Name:ALTAMONTE PEDIATRIC ASSOCIATES
Entity type:Organization
Organization Name:ALTAMONTE PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-831-6200
Mailing Address - Street 1:475 OSCEOLA ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-7857
Mailing Address - Country:US
Mailing Address - Phone:407-831-6200
Mailing Address - Fax:407-831-1068
Practice Address - Street 1:475 OSCEOLA ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-7857
Practice Address - Country:US
Practice Address - Phone:407-831-6200
Practice Address - Fax:407-831-1068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054254700Medicaid