Healthcare Provider Details

I. General information

NPI: 1316280167
Provider Name (Legal Business Name): ROBERT ANTHONY KICKISH JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2013
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14100 58TH ST N
CLEARWATER FL
33760-9900
US

IV. Provider business mailing address

2995 DREW ST
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 727-824-8181
  • Fax: 727-824-8165
Mailing address:
  • Phone: 727-281-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME126742
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: