Provider Demographics
NPI:1346726452
Name:KITTREDGE, JUSTIN P (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:P
Last Name:KITTREDGE
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 9430
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9430
Mailing Address - Country:US
Mailing Address - Phone:386-274-7800
Mailing Address - Fax:833-549-5578
Practice Address - Street 1:701 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3236
Practice Address - Country:US
Practice Address - Phone:386-943-4522
Practice Address - Fax:833-549-5578
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN27655390200000X
FLME149949207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110477800Medicaid
FLOMCPJOtherBCBS