1255396875 NPI number — CHILD NEUROLOGY CENTER OF ORLANDO, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255396875 NPI number — CHILD NEUROLOGY CENTER OF ORLANDO, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILD NEUROLOGY CENTER OF ORLANDO, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255396875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6000 TURKEY LAKE ROAD
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-649-1848
Provider Business Mailing Address Fax Number:
407-649-1979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6000 TURKEY LAKE ROAD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-649-1848
Provider Business Practice Location Address Fax Number:
407-649-1979
Provider Enumeration Date:
04/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOJIC
Authorized Official First Name:
JASNA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRSIDENT
Authorized Official Telephone Number:
407-649-1848

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  PEDIATRIC NEUROLOGY , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001848800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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