Provider Demographics
NPI:1265091391
Name:DEIDRICK, KELSEY (MD)
Entity type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:
Last Name:DEIDRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33325-1902
Mailing Address - Country:US
Mailing Address - Phone:954-812-5303
Mailing Address - Fax:
Practice Address - Street 1:1402 NE 26TH ST
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-1322
Practice Address - Country:US
Practice Address - Phone:954-563-3767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL28391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program