Provider Demographics
NPI:1053313700
Name:KANNER, ROBERT STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:STEPHEN
Last Name:KANNER
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 1:4800 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6004
Mailing Address - Country:US
Mailing Address - Phone:904-398-7205
Mailing Address - Fax:904-396-4047
Practice Address - Street 1:4800 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6004
Practice Address - Country:US
Practice Address - Phone:904-398-7205
Practice Address - Fax:904-396-4047
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29405207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065136200Medicaid
FL100003106OtherMEDICARE, RAILROAD
FL15469ZMedicare PIN
FLD52601Medicare UPIN