Provider Demographics
NPI:1730134644
Name:RIFKIN, KERRY VAUGHN (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:VAUGHN
Last Name:RIFKIN
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 1:2140 KINGSLEY AVE
Mailing Address - Street 2:SUITE 14
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5180
Mailing Address - Country:US
Mailing Address - Phone:904-276-7997
Mailing Address - Fax:904-276-7559
Practice Address - Street 1:2140 KINGSLEY AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5180
Practice Address - Country:US
Practice Address - Phone:904-276-7997
Practice Address - Fax:904-276-7559
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG40462086S0129X
FLME00415292086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067441900Medicaid
FL15764OtherBCBS OF FLORIDA
FL020016680OtherRAILROAD MEDICARE
FL067441900Medicaid
FL020016680OtherRAILROAD MEDICARE