Organization
FLORIDA PEDIATRIC ASSOCIATES, LLC
Active
Other names
Florida Pediatric Assoc Optical Maitland
Organization subpart
No
Provider details
NPI number
Authorized official
SHEILA A TATHAM (CREDENTIALING MANAGER)
(727) 456-4250
Entity
Organization
Contact information
Practice address
790 CONCOURSE PKWY S, SUITE 200, MAITLAND, FL 32751-6114
(407) 767-6411
(407) 767-8160
Mailing address
1033 DR MARTIN LUTHER KING JR ST N, SUITE 108, ST PETERSBURG, FL 33701-1547
(727) 456-3288
(727) 456-3289
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
256303739
—
FL
01
—
38313
MEDICARE PTAN
FL
Enumeration date
12/07/2010
Last updated
12/07/2010
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