Provider Demographics
NPI:1841289204
Name:PROFESSIONAL PARK PEDIATRICS P.A.
Entity type:Organization
Organization Name:PROFESSIONAL PARK PEDIATRICS P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:G
Authorized Official - Last Name:BUNNELL
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:850-402-5454
Mailing Address - Street 1:1881 PROFESSIONAL PARK CIR
Mailing Address - Street 2:SUITE 80
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4541
Mailing Address - Country:US
Mailing Address - Phone:850-402-5454
Mailing Address - Fax:850-402-5451
Practice Address - Street 1:1881 PROFESSIONAL PARK CIR
Practice Address - Street 2:SUITE 80
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4541
Practice Address - Country:US
Practice Address - Phone:850-402-5454
Practice Address - Fax:850-402-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91797208000000X
FLME37597208000000X
FLME75773208000000X
FLME82183208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty