Healthcare Provider Details

I. General information

NPI: 1073645594
Provider Name (Legal Business Name): HEIDI-MARIE ALEXANDRA KELLOCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEIDI-MARIE ALEXANDRA FARINHOLT MD

II. Dates (important events)

Enumeration Date: 03/10/2007
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

V. Phone/Fax

Practice location:
  • Phone: 352-733-0111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberME114140
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberME114140
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME114140
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberME114140
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME114140
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: