=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235189457
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HITEN VITHAL KISNAD M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 03/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3840 BELFORT RD STE 306
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-8210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-854-9177
-----------------------------------------------------
Fax | 904-854-6696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3840 BELFORT RD STE 306
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-8210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-854-9177
-----------------------------------------------------
Fax | 904-854-6696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME66482
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME0066482
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------