Provider Demographics
NPI:1770731291
Name:PALM BAY PEDIATRICS
Entity type:Organization
Organization Name:PALM BAY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:MARGARITA
Authorized Official - Last Name:LEEDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-722-8435
Mailing Address - Street 1:775 MALABAR RD
Mailing Address - Street 2:
Mailing Address - City:MALABAR
Mailing Address - State:FL
Mailing Address - Zip Code:32950-3120
Mailing Address - Country:US
Mailing Address - Phone:321-722-8435
Mailing Address - Fax:321-722-8486
Practice Address - Street 1:775 MALABAR RD
Practice Address - Street 2:
Practice Address - City:MALABAR
Practice Address - State:FL
Practice Address - Zip Code:32950-3120
Practice Address - Country:US
Practice Address - Phone:321-722-8435
Practice Address - Fax:321-722-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME637472080P0205X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL632833OtherAETNA
FLE41429OtherUPIN
FL3736201002OtherCIGNA
FL372797100Medicaid
FL18683OtherBLUE CROSS BLUE SHIELD
FL632833OtherAETNA
FL=========OtherTAX ID NUMBER
FL372797100Medicaid