Provider Demographics
NPI:1851345714
Name:NIXON, KENNETH E (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:NIXON
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 1:515 W 6TH ST
Mailing Address - Street 2:MC #24
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4324
Mailing Address - Country:US
Mailing Address - Phone:904-665-2410
Mailing Address - Fax:904-630-3316
Practice Address - Street 1:1760 EDGEWOOD AVE W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-7209
Practice Address - Country:US
Practice Address - Phone:904-253-1030
Practice Address - Fax:904-924-1773
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271082000Medicaid
52039XMedicare ID - Type Unspecified
I21395Medicare UPIN