Healthcare Provider Details

I. General information

NPI: 1043763865
Provider Name (Legal Business Name): KELLY DUGGIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8340 LAKEWOOD RANCH BLVD SUITE 210
BRADENTON FL
34202-5185
US

IV. Provider business mailing address

367 S. GULPH RD ATTN: IPM CREDENTIALING
KING OF PRUSSIA PA
19406-3121
US

V. Phone/Fax

Practice location:
  • Phone: 941-782-2800
  • Fax: 941-782-2513
Mailing address:
  • Phone: 941-782-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR-10693
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME140197
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: