Provider Demographics
NPI:1356513964
Name:MAGNOLIA PEDIATRICS LLC
Entity type:Organization
Organization Name:MAGNOLIA PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BILAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-719-6500
Mailing Address - Street 1:1140 SW BASCOM NORRIS DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1329
Mailing Address - Country:US
Mailing Address - Phone:386-719-6500
Mailing Address - Fax:386-719-6503
Practice Address - Street 1:1140 SW BASCOM NORRIS DR STE 104
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1329
Practice Address - Country:US
Practice Address - Phone:386-719-6500
Practice Address - Fax:386-719-6503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72652208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061823792OtherTRICARE