Provider Demographics
NPI:1871679357
Name:DDK LC
Entity Type:Organization
Organization Name:DDK LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:KIDDY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:636-281-8393
Mailing Address - Street 1:300 WINDING WOODS DRIVE
Mailing Address - Street 2:SUITE 214
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366
Mailing Address - Country:US
Mailing Address - Phone:636-281-8393
Mailing Address - Fax:636-281-1808
Practice Address - Street 1:300 WINDING WOODS DRIVE
Practice Address - Street 2:SUITE 214
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366
Practice Address - Country:US
Practice Address - Phone:636-281-8393
Practice Address - Fax:636-281-1808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505041400Medicaid
MO505041400Medicaid
CG9605Medicare PIN
AR5F808Medicare PIN