Provider Demographics
NPI:1750675161
Name:CRICK, KATHLEEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:CRICK
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 1:734 S MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-4212
Mailing Address - Country:US
Mailing Address - Phone:904-318-4680
Mailing Address - Fax:407-872-0544
Practice Address - Street 1:86 W UNDERWOOD ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1110
Practice Address - Country:US
Practice Address - Phone:407-649-6876
Practice Address - Fax:407-872-0544
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL120486208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist