Provider Demographics
NPI:1316338858
Name:WICKHAM PEDIATRICS CENTER PS
Entity type:Organization
Organization Name:WICKHAM PEDIATRICS CENTER PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNTER
Authorized Official - Prefix:DR
Authorized Official - First Name:KANEEZ
Authorized Official - Middle Name:
Authorized Official - Last Name:AGHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-953-5364
Mailing Address - Street 1:199 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1131
Mailing Address - Country:US
Mailing Address - Phone:321-953-5364
Mailing Address - Fax:321-953-9975
Practice Address - Street 1:199 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1131
Practice Address - Country:US
Practice Address - Phone:321-953-5364
Practice Address - Fax:321-953-9975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250730700Medicaid