Provider Demographics
NPI:1053747188
Name:PEDIATRICS & FAMILY MEDICINE OF BUENA VISTA , LLC
Entity type:Organization
Organization Name:PEDIATRICS & FAMILY MEDICINE OF BUENA VISTA , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BILAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-213-1243
Mailing Address - Street 1:519 BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10552 NW 13TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-8088
Practice Address - Country:US
Practice Address - Phone:678-570-5063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072652261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252009500Medicaid