1144214529 NPI number — DANIEL DOUGLAS KIDDY DPM

Table of content: DANIEL DOUGLAS KIDDY DPM (NPI 1144214529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144214529 NPI number — DANIEL DOUGLAS KIDDY DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIDDY
Provider First Name:
DANIEL
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1144214529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14780 W MOUNTAIN VIEW BLVD
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
SURPRISE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85374-7280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-374-7774
Provider Business Mailing Address Fax Number:
855-420-6361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 WINDING WOODS DR
Provider Second Line Business Practice Location Address:
STE 214
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63366-4771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-281-8393
Provider Business Practice Location Address Fax Number:
636-281-1808
Provider Enumeration Date:
08/31/2005

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: 213E00000X , with the licence number:  000681 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 303557003 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com