1801978457 NPI number — RAYMOND EARL KIDWELL MD

Table of content: RAYMOND EARL KIDWELL MD (NPI 1801978457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801978457 NPI number — RAYMOND EARL KIDWELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIDWELL
Provider First Name:
RAYMOND
Provider Middle Name:
EARL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801978457
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 W HERNDON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93612-0204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-298-7220
Provider Business Mailing Address Fax Number:
909-557-1924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 HERNDON AVENUE
Provider Second Line Business Practice Location Address:
SUITE 131
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-298-7220
Provider Business Practice Location Address Fax Number:
559-298-7060
Provider Enumeration Date:
10/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A66131 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: A66131 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00439927 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P00767385 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".