Provider Demographics
NPI:1518140128
Name:KILGORE, JOHN M (MC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:KILGORE
Suffix:
Gender:M
Credentials:MC
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 128
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33509-0128
Mailing Address - Country:US
Mailing Address - Phone:813-965-3092
Mailing Address - Fax:813-754-7587
Practice Address - Street 1:235 W BRANDON BLVD STE 128
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5103
Practice Address - Country:US
Practice Address - Phone:813-965-3092
Practice Address - Fax:813-754-7587
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30318174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE38465Medicare UPIN