Provider Demographics
NPI:1548757883
Name:ROCKWELL, KYLE THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:THOMAS
Last Name:ROCKWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6525 3RD ST STE 302
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-5749
Practice Address - Country:US
Practice Address - Phone:321-241-1144
Practice Address - Fax:321-806-3878
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS18821207QS0010X
00000000000000000000390200000X
OH58.030496207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH346OtherHF MA
FL114175400Medicaid