Provider Demographics
NPI:1932136025
Name:VANOSDOL, KENNETH M (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:VANOSDOL
Suffix:
Gender:M
Credentials:PA
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 863026
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3026
Mailing Address - Country:US
Mailing Address - Phone:904-346-5426
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:1800 BARRS ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4704
Practice Address - Country:US
Practice Address - Phone:904-303-8730
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1027204207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7239ZMedicare ID - Type Unspecified
FLE1471WMedicare PIN
FLS66363Medicare UPIN