Provider Demographics
NPI:1770503377
Name:HANYZESKI, KHANH KIM (DO)
Entity Type:Individual
Prefix:
First Name:KHANH
Middle Name:KIM
Last Name:HANYZESKI
Suffix:
Gender:F
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1400
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:19910 S TAMIAMI TRL STE C
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-4140
Practice Address - Country:US
Practice Address - Phone:239-498-6912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6722207PE0004X
FLOS 9865207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121318305Medicaid
FL277699500Medicaid
TX8C0337Medicare ID - Type Unspecified
FLAC247ZMedicare PIN