Healthcare Provider Details

I. General information

NPI: 1770576332
Provider Name (Legal Business Name): KYLE R. ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 MALABAR RD
MALABAR FL
32950-3140
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-409-6800
  • Fax: 321-409-6812
Mailing address:
  • Phone: 321-409-6800
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME56150
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: