Provider Demographics
NPI:1992067342
Name:WEST FLORIDA PEDIATRICS
Entity type:Organization
Organization Name:WEST FLORIDA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:UDAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HIREMATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-746-3338
Mailing Address - Street 1:3733 E GULF TO LAKE HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34453-3206
Mailing Address - Country:US
Mailing Address - Phone:352-746-3338
Mailing Address - Fax:352-344-3414
Practice Address - Street 1:3733 E GULF TO LAKE HWY
Practice Address - Street 2:SUITE B
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-3206
Practice Address - Country:US
Practice Address - Phone:352-746-3338
Practice Address - Fax:352-344-3414
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST FLORIDA MEDICAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90418208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252639501Medicaid