Provider Demographics
NPI:1316042286
Name:KNICKERBOCKER, DONALD E (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:E
Last Name:KNICKERBOCKER
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:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-334-1340
Mailing Address - Fax:352-334-1348
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-334-1340
Practice Address - Fax:352-334-1348
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDK024810208000000X
FLME47750208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046945900Medicaid
MI2999422Medicaid
MIE14486Medicare UPIN
MI2999422Medicaid