Basic Information
| Provider Information | |||||||||
| NPI: | 1689114480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDZ MEDICAL SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5955 PONCE DE LEON BLVD | ||||||||
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| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331462423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056611515 | ||||||||
| FaxNumber: | 3056635948 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 SW 148TH AVE | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330274181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549679400 | ||||||||
| FaxNumber: | 9549679551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2017 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | PEREZ | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3056611515 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | ME58352 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 257829800 | 05 | FL | MEDICAID |