Provider Demographics
NPI:1316407612
Name:LIST, KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LIST
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 1:1578 W ORANGE BLOSSOM TRL
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-2639
Mailing Address - Country:US
Mailing Address - Phone:407-635-3240
Mailing Address - Fax:407-636-7847
Practice Address - Street 1:1578 W ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-2639
Practice Address - Country:US
Practice Address - Phone:407-635-3240
Practice Address - Fax:407-636-7847
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME161624207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118675400Medicaid