Basic Information
| Provider Information | |||||||||
| NPI: | 1730215112 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDSTOWN PEDIATRICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7800 SW 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331733570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547319676 | ||||||||
| FaxNumber: | 9547319747 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 NE 89TH ST | ||||||||
| Address2: | |||||||||
| City: | EL PORTAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331383119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055765437 | ||||||||
| FaxNumber: | 3055765120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 10/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | OKONKWO | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 3055765437 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 74168 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 269200700 | 05 | FL | MEDICAID |