Provider Demographics
NPI:1720082076
Name:STATUM, KASEY A (MD)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:A
Last Name:STATUM
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 1:4437 N CANDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-8907
Mailing Address - Country:US
Mailing Address - Phone:301-254-4316
Mailing Address - Fax:
Practice Address - Street 1:1500 LAKELAND HILLS BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3257
Practice Address - Country:US
Practice Address - Phone:832-242-4735
Practice Address - Fax:239-302-1344
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21877208000000X
VA0101246540208000000X
NY227551208000000X
FLME114685208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003695Medicaid
WV3810003695Medicaid
WV2026731Medicare PIN