Provider Demographics
NPI:1437454352
Name:KIDD MEDICAL CONCEPTS PLLC
Entity Type:Organization
Organization Name:KIDD MEDICAL CONCEPTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:AVIAN
Authorized Official - Middle Name:DESHIVER
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-505-1584
Mailing Address - Street 1:PO BOX 8887
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75404-8887
Mailing Address - Country:US
Mailing Address - Phone:903-200-1277
Mailing Address - Fax:903-269-3503
Practice Address - Street 1:2900 MCKINNON ST APT 502
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-1064
Practice Address - Country:US
Practice Address - Phone:972-505-1584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1829207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM1829OtherLICENCE
TXTXB124912OtherMEDICARE PART B