Provider Demographics
NPI:1326022195
Name:HITZ, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:HITZ
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 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-326-7342
Mailing Address - Fax:386-325-1086
Practice Address - Street 1:1955 US HIGHWAY 1 S
Practice Address - Street 2:WING D-EAST
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3708
Practice Address - Country:US
Practice Address - Phone:904-829-2530
Practice Address - Fax:386-325-1086
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 89307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277317100Medicaid
FLP00321213Medicare PIN
FL37609AMedicare PIN
FL37609WMedicare PIN