Basic Information
Provider Information | |||||||||
NPI: | 1508526435 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NIGHT LITE PEDIATRIC CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5900 S JOHN YOUNG PKWY | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328393716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073986470 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5900 S JOHN YOUNG PKWY | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328393716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073986470 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2021 | ||||||||
LastUpdateDate: | 01/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DESAI | ||||||||
AuthorizedOfficialFirstName: | VIVEK | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4073986470 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 01/19/2022 |
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 | 370410601 | 05 | FL |   | MEDICAID |