MEDICARE: KEVIN TRAHAN IDMT

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	247200000X	Other Technician
2	1710I1002X	Independent Duty Corpsman

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710I1003X	OTHER	FL	IDMT

General Provider Information

NPI Number	:	1598744021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN TRAHAN IDMT

Provider Business Mailing Address
First Line	:	4200 OCEAN ST
Second Line	:
City	:	ATLANTIC BEACH
State	:	FL
Zip	:	32233-2416
Country	:	US
Telephone Number	:	904-564-7581
Fax Number	:	904-564-7583

Provider Business Practice Location Address
First Line	:	4200 OCEAN ST
Second Line	:
City	:	ATLANTIC BEACH
State	:	FL
Zip	:	32233-2416
Country	:	US
Telephone Number	:	904-564-7581
Fax Number	:

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

Provider Enumeration Date	:	01/12/2006
Last Update Date	:	09/11/2025

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Directions to “ KEVIN TRAHAN IDMT” Practice Location

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