Provider Demographics
NPI:1578854733
Name:HUMPHREYS, KEVIN DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DANIEL
Last Name:HUMPHREYS
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 1:34041 US HIGHWAY 19 N STE A
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-2648
Mailing Address - Country:US
Mailing Address - Phone:727-786-0017
Mailing Address - Fax:727-786-7521
Practice Address - Street 1:34041 US 19 N STE A
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-2648
Practice Address - Country:US
Practice Address - Phone:727-786-0017
Practice Address - Fax:727-786-7521
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119076207R00000X
NC173041207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14V1EOtherBLUE CROSS BLUE SHIELD
FL012208800Medicaid
FL012208800Medicaid