Healthcare Provider Details

I. General information

NPI: 1437454352
Provider Name (Legal Business Name): KIDD MEDICAL CONCEPTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 MCKINNON ST APT 502
DALLAS TX
75201-1064
US

IV. Provider business mailing address

PO BOX 8887
GREENVILLE TX
75404-8887
US

V. Phone/Fax

Practice location:
  • Phone: 972-505-1584
  • Fax:
Mailing address:
  • Phone: 903-200-1277
  • Fax: 903-269-3503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM1829
License Number StateTX

VIII. Authorized Official

Name: DR. AVIAN DESHIVER KIDD
Title or Position: PRESIDENT & PROVIDER
Credential: MD
Phone: 972-505-1584