MEDICARE: KIBIBI DAVISON DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	PO4035	FL
2	213E00000X	Podiatrist	SC006042	PA
3	213EP1101X	Primary Podiatric Medicine Podiatrist	07001101A	IN
4	390200000X	Student in an Organized Health Care Education/Training Program	SC006042	PA
5	213EP1101X	Primary Podiatric Medicine Podiatrist	016.005441	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063676575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIBIBI DAVISON DPM

Provider Business Mailing Address
First Line	:	7532 CLEARVIEW DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-2930
Country	:	US
Telephone Number	:	813-525-6135
Fax Number	:

Provider Business Practice Location Address
First Line	:	7532 CLEARVIEW DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634
Country	:	US
Telephone Number	:	813-525-6135
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2008
Last Update Date	:	03/11/2019

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Directions to “ KIBIBI DAVISON DPM” Practice Location

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