Provider Demographics
NPI:1215901723
Name:KIDSVILLE PEDIATRICS III, P.A.
Entity type:Organization
Organization Name:KIDSVILLE PEDIATRICS III, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:PANTOJA JR.
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-242-1021
Mailing Address - Street 1:1804 OAKLEY SEAVER BLVD
Mailing Address - Street 2:SUITE-C
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1925
Mailing Address - Country:US
Mailing Address - Phone:352-242-1021
Mailing Address - Fax:352-242-1104
Practice Address - Street 1:1804 OAKLEY SEAVER BLVD
Practice Address - Street 2:SUITE-C
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1925
Practice Address - Country:US
Practice Address - Phone:352-242-1021
Practice Address - Fax:352-242-1104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001599400Medicaid
FL125226800Medicaid
FLFL206AOtherMEDICARE