Provider Demographics
NPI:1982743050
Name:KNIZLEY ENDOCRINE AND DIABETIC CARE, PA
Entity Type:Organization
Organization Name:KNIZLEY ENDOCRINE AND DIABETIC CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOMER
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIZLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:352-332-7990
Mailing Address - Street 1:6800 NW 9TH BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4231
Mailing Address - Country:US
Mailing Address - Phone:352-332-7990
Mailing Address - Fax:352-332-9894
Practice Address - Street 1:6800 NW 9TH BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4231
Practice Address - Country:US
Practice Address - Phone:352-332-7990
Practice Address - Fax:352-332-9894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME13674207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01801OtherBLUE SHIELD
FL01801Medicare ID - Type Unspecified
FLD82300Medicare UPIN