Healthcare Provider Details

I. General information

NPI: 1801978457
Provider Name (Legal Business Name): RAYMOND EARL KIDWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 HERNDON AVENUE SUITE 131
CLOVIS CA
93612
US

IV. Provider business mailing address

275 W HERNDON AVE
CLOVIS CA
93612-0204
US

V. Phone/Fax

Practice location:
  • Phone: 559-298-7220
  • Fax: 559-298-7060
Mailing address:
  • Phone: 559-298-7220
  • Fax: 909-557-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA66131
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA66131
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: