Provider Demographics
NPI:1033103361
Name:KISKADDON, BRUCE M (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
Last Name:KISKADDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43309 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-6221
Mailing Address - Country:US
Mailing Address - Phone:727-943-3111
Mailing Address - Fax:727-943-3334
Practice Address - Street 1:43309 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-6221
Practice Address - Country:US
Practice Address - Phone:727-943-3111
Practice Address - Fax:727-943-3334
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35851207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL484087OtherCIGNA
FL202008OtherAMERIGROUP
0027100OtherGHI
FL209961OtherAVMED
FL51112OtherBCBS
FL202008OtherAMERIGROUP
FL484087OtherCIGNA