Provider Demographics
NPI:1144214529
Name:KIDDY, DANIEL DOUGLAS (DPM)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:DOUGLAS
Last Name:KIDDY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14780 W MOUNTAIN VIEW BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7280
Mailing Address - Country:US
Mailing Address - Phone:623-374-7774
Mailing Address - Fax:855-420-6361
Practice Address - Street 1:300 WINDING WOODS DR
Practice Address - Street 2:STE 214
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-4771
Practice Address - Country:US
Practice Address - Phone:636-281-8393
Practice Address - Fax:636-281-1808
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2018-06-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO000681213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO303557003Medicaid
480013628Medicare PIN
MO303557003Medicaid
U32142Medicare UPIN
0463550001Medicare NSC