Provider Demographics
NPI:1063433076
Name:HEARTLAND PEDIATRICS OF LAKE WALES, P.A.
Entity type:Organization
Organization Name:HEARTLAND PEDIATRICS OF LAKE WALES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJESWARI
Authorized Official - Middle Name:
Authorized Official - Last Name:SONNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-679-8888
Mailing Address - Street 1:1356 STATE ROAD 60 E
Mailing Address - Street 2:ORANGE GROVE PLAZA
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4322
Mailing Address - Country:US
Mailing Address - Phone:863-679-8888
Mailing Address - Fax:863-676-2851
Practice Address - Street 1:1356 STATE ROAD 60 E
Practice Address - Street 2:ORANGE GROVE PLAZA
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4322
Practice Address - Country:US
Practice Address - Phone:863-679-8888
Practice Address - Fax:863-676-2851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21247Medicare ID - Type UnspecifiedBC/BS
FL10-3968Medicare ID - Type UnspecifiedRHC, I.D. #