Provider Demographics
NPI:1720063993
Name:BERDICK, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:BERDICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3714 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9303
Mailing Address - Country:US
Mailing Address - Phone:239-334-4157
Mailing Address - Fax:239-334-1904
Practice Address - Street 1:3714 EVANS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9303
Practice Address - Country:US
Practice Address - Phone:239-334-4157
Practice Address - Fax:239-334-1904
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-10
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0017772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066122800Medicaid
FL91309Medicare ID - Type Unspecified
FL066122800Medicaid