Provider Demographics
NPI:1912000696
Name:HUSAIN, KISHWAR (MD)
Entity Type:Individual
Prefix:
First Name:KISHWAR
Middle Name:
Last Name:HUSAIN
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:PO BOX 860305
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-0305
Mailing Address - Country:US
Mailing Address - Phone:904-824-8666
Mailing Address - Fax:904-824-8933
Practice Address - Street 1:300 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 4000
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3707
Practice Address - Country:US
Practice Address - Phone:904-824-8666
Practice Address - Fax:904-824-8933
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68363207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00290670OtherRAILROAD MEDICARE
FL378472000Medicaid
FLE83750Medicare UPIN
FL27434YMedicare ID - Type Unspecified