Healthcare Provider Details

I. General information

NPI: 1720082076
Provider Name (Legal Business Name): KASEY A STATUM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 11/27/2023
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LAKELAND HILLS BLVD STE 1
LAKELAND FL
33805-3257
US

IV. Provider business mailing address

4437 N CANDLEWOOD DR
BEVERLY HILLS FL
34465-8907
US

V. Phone/Fax

Practice location:
  • Phone: 832-242-4735
  • Fax: 239-302-1344
Mailing address:
  • Phone: 301-254-4316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21877
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101246540
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number227551
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME114685
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: