Provider Demographics
NPI:1114064599
Name:KILGORE, MANLEY W II (MD)
Entity Type:Individual
Prefix:
First Name:MANLEY
Middle Name:W
Last Name:KILGORE
Suffix:II
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 1:836 PRUDENTIAL DR
Mailing Address - Street 2:SUITE 1601
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8334
Mailing Address - Country:US
Mailing Address - Phone:904-396-2400
Mailing Address - Fax:904-396-3750
Practice Address - Street 1:836 PRUDENTIAL DR
Practice Address - Street 2:SUITE 1601
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8334
Practice Address - Country:US
Practice Address - Phone:904-396-2400
Practice Address - Fax:904-396-3750
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME171332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16947OtherBLUE CROSS BLUE SHEILD
FLD53104Medicare UPIN
FL16947ZMedicare ID - Type Unspecified