Provider Demographics
NPI:1386239663
Name:KIDZMD, LLC
Entity type:Organization
Organization Name:KIDZMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN-RAGAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-492-2338
Mailing Address - Street 1:7234 STILL POND LN
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-0147
Mailing Address - Country:US
Mailing Address - Phone:407-492-2338
Mailing Address - Fax:
Practice Address - Street 1:5979 VINELAND RD STE 111
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7855
Practice Address - Country:US
Practice Address - Phone:407-492-2338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280511100Medicaid