Healthcare Provider Details

I. General information

NPI: 1801813852
Provider Name (Legal Business Name): KIRK P DOCKENDORF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LONGWOOD AVE
ROCKLEDGE FL
32955-2828
US

IV. Provider business mailing address

3740 BRENNAN DR
MELBOURNE FL
32934-8341
US

V. Phone/Fax

Practice location:
  • Phone: 321-637-2616
  • Fax: 321-637-2986
Mailing address:
  • Phone: 321-242-9369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME91506
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: