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General NPI Number Information
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NPI Number | 1437454352
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Entity Type | Organization
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Legal Business Name | KIDD MEDICAL CONCEPTS PLLC
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Dates
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Enumeration Date | 01/25/2011
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Last Update Date | 10/08/2019
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Provider Practice Location Address
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Address Line | 2900 MCKINNON ST APT 502
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City | DALLAS
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State | TX
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Zip | 75201-1064
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Country | US
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Telephone | 972-505-1584
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8887
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City | GREENVILLE
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State | TX
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Zip | 75404-8887
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Country | US
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Telephone | 903-200-1277
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Fax | 903-269-3503
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Authorized Official
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Title or Position | PRESIDENT & PROVIDER
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Name | DR. AVIAN DESHIVER KIDD
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Credential | MD
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Telephone | 972-505-1584
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | M1829
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License Number State | TX
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