Provider Demographics
NPI:1063676575
Name:DAVISON, KIBIBI (DPM)
Entity Type:Individual
Prefix:
First Name:KIBIBI
Middle Name:
Last Name:DAVISON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7532 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-2930
Mailing Address - Country:US
Mailing Address - Phone:813-525-6135
Mailing Address - Fax:
Practice Address - Street 1:7532 CLEARVIEW DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634
Practice Address - Country:US
Practice Address - Phone:813-525-6135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4035213E00000X
PASC006042213E00000X, 390200000X
IN07001101A213EP1101X
IL016.005441213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1692001Medicare PIN
ILF400100794Medicare PIN