Provider Demographics
NPI:1902084064
Name:PORT ORANGE PEDIATRICS P A
Entity Type:Organization
Organization Name:PORT ORANGE PEDIATRICS P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-322-5390
Mailing Address - Street 1:1728 DUNLAWTON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-2923
Mailing Address - Country:US
Mailing Address - Phone:386-322-5390
Mailing Address - Fax:386-322-5391
Practice Address - Street 1:1720 DUNLAWTON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-2915
Practice Address - Country:US
Practice Address - Phone:386-322-5390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068668208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty