Provider Demographics
NPI:1932516408
Name:CHILDREN'S DOCTORS CLINIC
Entity Type:Organization
Organization Name:CHILDREN'S DOCTORS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PANITDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:TOOCHINDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-913-2156
Mailing Address - Street 1:855 E SANDPIPER ST
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-2903
Mailing Address - Country:US
Mailing Address - Phone:407-889-3175
Mailing Address - Fax:
Practice Address - Street 1:264 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-3336
Practice Address - Country:US
Practice Address - Phone:407-862-8448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29981302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059989100Medicaid