Provider Demographics
NPI:1619237369
Name:TEPEDINO, KELLY DIANE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:TEPEDINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 SW NEWLAND WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6915
Mailing Address - Country:US
Mailing Address - Phone:386-344-6102
Mailing Address - Fax:
Practice Address - Street 1:1722 SW NEWLAND WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6915
Practice Address - Country:US
Practice Address - Phone:386-344-6102
Practice Address - Fax:386-344-6103
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122956207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9ZCR4OtherFL BLUE