1831362805 NPI number — LAKE WALE PEDIATRIC INTERNAL MEDICINE P.A.

Table of content: (NPI 1831362805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831362805 NPI number — LAKE WALE PEDIATRIC INTERNAL MEDICINE P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE WALE PEDIATRIC INTERNAL MEDICINE 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:
1831362805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 S 11TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE WALES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33853-4239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-676-8935
Provider Business Mailing Address Fax Number:
863-679-2691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 S 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WALES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33853-4239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-676-8935
Provider Business Practice Location Address Fax Number:
863-679-2691
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
OROPEZA
Authorized Official First Name:
OSCAR
Authorized Official Middle Name:
AMADOR
Authorized Official Title or Position:
MEDICAL DOCTOR
Authorized Official Telephone Number:
863-676-8935

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  ME87271-ME90317 , 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: AL 597 . This is a "MEDICARE PROVIDER GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000808300 . 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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