Provider Demographics
NPI:1336384643
Name:VIDYA P KINI MD PL
Entity type:Organization
Organization Name:VIDYA P KINI MD PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIDYA
Authorized Official - Middle Name:P
Authorized Official - Last Name:KINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-274-5464
Mailing Address - Street 1:35 BARKLEY CIR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7601
Mailing Address - Country:US
Mailing Address - Phone:239-274-5464
Mailing Address - Fax:
Practice Address - Street 1:35 BARKLEY CIR
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7601
Practice Address - Country:US
Practice Address - Phone:239-274-5464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56122174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036091100Medicaid
FL4122518OtherAETNA
FL3720007001OtherCIGNA
FL3720007001OtherCIGNA
FLE22643Medicare UPIN