1205399060 NPI number — DAYTONA PEDIATRICS

Table of content: (NPI 1205399060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205399060 NPI number — DAYTONA PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAYTONA PEDIATRICS
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:
1205399060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67 COQUINA RIDGE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174-1812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-366-4873
Provider Business Mailing Address Fax Number:
386-676-2555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 BIG TREE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH DAYTONA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32119-2517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-676-0255
Provider Business Practice Location Address Fax Number:
386-676-2555
Provider Enumeration Date:
04/09/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SINGH
Authorized Official First Name:
AMAR
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
386-366-4873

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 271799900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103132200 . 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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