Provider Demographics
NPI:1033455910
Name:C. KIRK DEMARTINO M.D. PA
Entity Type:Organization
Organization Name:C. KIRK DEMARTINO M.D. PA
Other - Org Name:ISLAND DOCTOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CIRO
Authorized Official - Middle Name:KIRK
Authorized Official - Last Name:DEMARTINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-642-5552
Mailing Address - Street 1:950 N COLLIER BLVD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-2725
Mailing Address - Country:US
Mailing Address - Phone:239-642-5552
Mailing Address - Fax:239-642-5565
Practice Address - Street 1:950 N COLLIER BLVD
Practice Address - Street 2:SUITE 308
Practice Address - City:MARCO ISLAND
Practice Address - State:FL
Practice Address - Zip Code:34145-2725
Practice Address - Country:US
Practice Address - Phone:239-642-5552
Practice Address - Fax:239-642-5565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-20
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH91273Medicare UPIN