Healthcare Provider Details

I. General information

NPI: 1366962979
Provider Name (Legal Business Name): KANOULD DOLCINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2017
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 NW UNIVERSITY BLVD STE 102
PORT SAINT LUCIE FL
34986-2280
US

IV. Provider business mailing address

540 NW UNIVERSITY BLVD STE 102
PORT SAINT LUCIE FL
34986-2280
US

V. Phone/Fax

Practice location:
  • Phone: 772-310-1567
  • Fax: 772-673-3866
Mailing address:
  • Phone: 772-310-1567
  • Fax: 772-673-3866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1141
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: