Healthcare Provider Details

I. General information

NPI: 1275945800
Provider Name (Legal Business Name): COLLIN KITCHELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 36TH STREET
VERO BEACH FL
32960-6574
US

IV. Provider business mailing address

1265 36TH STREET
VERO BEACH FL
32960-6574
US

V. Phone/Fax

Practice location:
  • Phone: 772-567-6340
  • Fax: 772-567-3564
Mailing address:
  • Phone: 772-567-6340
  • Fax: 772-567-3564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36871
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: