Provider Demographics
NPI:1912357146
Name:KIDWELL, ALLISON CARLO (DO)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:CARLO
Last Name:KIDWELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 W KING ST STE M
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2100
Mailing Address - Country:US
Mailing Address - Phone:989-729-4100
Mailing Address - Fax:989-729-4066
Practice Address - Street 1:802 W KING ST STE M
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2100
Practice Address - Country:US
Practice Address - Phone:989-729-4100
Practice Address - Fax:989-729-4066
Is Sole Proprietor?:No
Enumeration Date:2016-06-19
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101024617208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1912357146Medicaid