Provider Demographics
NPI:1790756450
Name:KENT, ELIZABETH C (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:C
Last Name:KENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:C
Other - Last Name:STOREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-432-8331
Mailing Address - Fax:813-976-7895
Practice Address - Street 1:4689 US HIGHWAY 17 STE 2-5
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4831
Practice Address - Country:US
Practice Address - Phone:904-269-6526
Practice Address - Fax:904-269-6527
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116639207RH0000X, 207RX0202X, 207RX0202X
KS04-30839207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009197200Medicaid
GA003146483BMedicaid
GA003146483BMedicaid
FL009197200Medicaid
KS200268740AMedicaid
FL7670596OtherAETNA
FLHJ402ZMedicare PIN
FLP01220941Medicare UPIN
KS200268740AMedicaid
FLHJ402YMedicare PIN
KS565D149DMedicare PIN