Provider Demographics
NPI:1942435920
Name:SANDFORD H KINNE III D O P A
Entity Type:Organization
Organization Name:SANDFORD H KINNE III D O P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SELF
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDFORD
Authorized Official - Middle Name:HALSEY
Authorized Official - Last Name:KINNE
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:386-677-5600
Mailing Address - Street 1:PO BOX 731869
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32173-1869
Mailing Address - Country:US
Mailing Address - Phone:386-677-5600
Mailing Address - Fax:386-677-5686
Practice Address - Street 1:290 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE A-1
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8130
Practice Address - Country:US
Practice Address - Phone:386-677-5600
Practice Address - Fax:386-677-5686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375409000Medicaid
FL375409000Medicaid