Healthcare Provider Details

I. General information

NPI: 1093195398
Provider Name (Legal Business Name): KYLE NATHANIEL CORRELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2744
US

IV. Provider business mailing address

320 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2744
US

V. Phone/Fax

Practice location:
  • Phone: 386-238-3242
  • Fax: 386-238-3223
Mailing address:
  • Phone: 386-238-3242
  • Fax: 386-238-3223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberME130000
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME130000
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: