Provider Demographics
NPI:1538453428
Name:KIDSVILLE PEDIATRICS VII, P.A. AFTER HOURS WALK-IN CLINIC
Entity type:Organization
Organization Name:KIDSVILLE PEDIATRICS VII, P.A. AFTER HOURS WALK-IN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:PANTOJA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:863-419-0688
Mailing Address - Street 1:2201 NORTH BLVD W
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-8990
Mailing Address - Country:US
Mailing Address - Phone:863-419-0688
Mailing Address - Fax:863-419-9547
Practice Address - Street 1:2201 NORTH BLVD W
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8990
Practice Address - Country:US
Practice Address - Phone:863-419-0688
Practice Address - Fax:863-419-9547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-0074421208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty