Provider Demographics
NPI:1992730550
Name:PROGRESSIVE PEDIATRICS OF ORLANDO PA
Entity type:Organization
Organization Name:PROGRESSIVE PEDIATRICS OF ORLANDO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRELES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-830-5437
Mailing Address - Street 1:PO BOX 520879
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32752-0879
Mailing Address - Country:US
Mailing Address - Phone:407-830-5437
Mailing Address - Fax:407-834-4907
Practice Address - Street 1:521 W STATE ROAD 434
Practice Address - Street 2:SUITE 101
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750
Practice Address - Country:US
Practice Address - Phone:407-830-5437
Practice Address - Fax:407-834-4907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54968208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272040000Medicaid
D88992Medicare UPIN