Healthcare Provider Details

I. General information

NPI: 1700810421
Provider Name (Legal Business Name): RICHARD CHARLES KIDD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13020 PARK BLVD OAKHURST MEDICAL CLINIC
SEMINOLE FL
33776
US

IV. Provider business mailing address

13020 PARK BLVD OAKHURST MEDICAL CLINIC
SEMINOLE FL
33776
US

V. Phone/Fax

Practice location:
  • Phone: 727-393-3404
  • Fax: 727-393-4814
Mailing address:
  • Phone: 727-393-3404
  • Fax: 727-393-4814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS0002974
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: