Provider Demographics
NPI:1487731931
Name:SUNSHINE PEDIATRICS OF BREVARD
Entity type:Organization
Organization Name:SUNSHINE PEDIATRICS OF BREVARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:MANTECON
Authorized Official - Last Name:MATEOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-254-8400
Mailing Address - Street 1:445 PINEDA CT
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7555
Mailing Address - Country:US
Mailing Address - Phone:321-254-8400
Mailing Address - Fax:321-254-7306
Practice Address - Street 1:445 PINEDA CT
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7555
Practice Address - Country:US
Practice Address - Phone:321-254-8400
Practice Address - Fax:321-254-7306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME594152080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058416900Medicaid
FL058052000Medicaid
FLF48373Medicare UPIN
FL058416900Medicaid