Provider Demographics
NPI:1346496460
Name:SHADDIX, KYLE KIT (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:KIT
Last Name:SHADDIX
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 1:5147 N 9TH AVE
Mailing Address - Street 2:STE. 203
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8771
Mailing Address - Country:US
Mailing Address - Phone:850-476-7100
Mailing Address - Fax:850-479-6042
Practice Address - Street 1:5147 N 9TH AVE
Practice Address - Street 2:STE 203
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8771
Practice Address - Country:US
Practice Address - Phone:850-476-7100
Practice Address - Fax:850-479-6042
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2015-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99596208600000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003155317AMedicaid
FL013852500Medicaid
FL013852500Medicaid