Provider Demographics
NPI:1821284589
Name:M.W. KILGORE, II, M.D., P.A.
Entity Type:Organization
Organization Name:M.W. KILGORE, II, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MANLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:904-396-2400
Mailing Address - Street 1:11363 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7957
Mailing Address - Country:US
Mailing Address - Phone:904-396-2400
Mailing Address - Fax:904-396-3750
Practice Address - Street 1:11363 SAN JOSE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7957
Practice Address - Country:US
Practice Address - Phone:904-396-2400
Practice Address - Fax:904-396-3750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME171332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059854200Medicaid