Provider Demographics
NPI:1700150943
Name:KENNETH W FIELDS DERMATOLOGY PA
Entity Type:Organization
Organization Name:KENNETH W FIELDS DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-262-7546
Mailing Address - Street 1:5100 TAMIAMI TRAIL N
Mailing Address - Street 2:102
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-2810
Mailing Address - Country:US
Mailing Address - Phone:239-262-7546
Mailing Address - Fax:239-262-2403
Practice Address - Street 1:5100 TAMIAMI TRAIL N
Practice Address - Street 2:102
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-2810
Practice Address - Country:US
Practice Address - Phone:239-262-7546
Practice Address - Fax:239-262-2403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045217207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08326OtherBLUE CROSS BLUE SHIELD FLORIDA
FL08326OtherMEDICARE FLORIDA
FL08326OtherBLUE CROSS BLUE SHIELD FLORIDA