Provider Demographics
NPI:1144343617
Name:EAST LAKE PEDIATRICS
Entity type:Organization
Organization Name:EAST LAKE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-372-6760
Mailing Address - Street 1:2137 LITTLE RD
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4410
Mailing Address - Country:US
Mailing Address - Phone:727-372-6760
Mailing Address - Fax:727-372-6808
Practice Address - Street 1:2137 LITTLE RD
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4410
Practice Address - Country:US
Practice Address - Phone:727-372-6760
Practice Address - Fax:727-372-6808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86866208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS9496OtherLICENSE NUMBER
FLOS9496OtherLICENSE NUMBER