Healthcare Provider Details

I. General information

NPI: 1245486323
Provider Name (Legal Business Name): RYAN LEE KJOME M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11215 METRO PKWY STE 1
FORT MYERS FL
33966-1206
US

IV. Provider business mailing address

11215 METRO PKWY STE 1
FORT MYERS FL
33966-1206
US

V. Phone/Fax

Practice location:
  • Phone: 239-208-2212
  • Fax:
Mailing address:
  • Phone: 239-208-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME152096
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM7336
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: