Provider Demographics
NPI:1114916368
Name:RAPPAPORT, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:RAPPAPORT
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 1:8833 PERIMETER PARK BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1111
Mailing Address - Country:US
Mailing Address - Phone:904-997-1100
Mailing Address - Fax:904-997-8080
Practice Address - Street 1:8833 PERIMETER PARK BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1111
Practice Address - Country:US
Practice Address - Phone:904-997-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80317207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4084Medicare ID - Type Unspecified
FLG76893Medicare UPIN