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Organization
PEDIATRIC ENT, LLC
Active
Organization
PEDIATRIC ENT, LLC
Active
Other names
Family ENT & Audiology
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DAVID JOEL MALIS MD (MANAGER)
(321) 254-5437
Entity
Organization
Contact information
Practice address
1499 S HARBOR CITY BLVD STE 303, MELBOURNE, FL 32901-3245
(321) 254-5437
(321) 254-4543
Mailing address
1499 S HARBOR CITY BLVD STE 303, MELBOURNE, FL 32901-3245
(321) 254-5437
(321) 254-4543
Taxonomy
Speciality
Code
Description
License number
State
207YP0228X
Pediatric Otolaryngology Physician
Primary
ME90348
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01269821
MEDICAID HMO - AMERIGROUP
FL
01
—
2258392
MEDICAID HMO - UNITED HEALTH CARE
FL
05
—
271247400
—
FL
01
—
332181
MEDICAID HMO - WELLCARE
FL
Enumeration date
01/05/2009
Last updated
04/18/2014
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