Provider Demographics
NPI:1366892150
Name:KIDWELL, MARK DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:KIDWELL
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:3955 PATIENT CARE DR STE A
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4271
Mailing Address - Country:US
Mailing Address - Phone:517-374-7600
Mailing Address - Fax:885-480-9150
Practice Address - Street 1:3955 PATIENT CARE DR STE A
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911
Practice Address - Country:US
Practice Address - Phone:517-374-7600
Practice Address - Fax:885-480-9150
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2025-03-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101022590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine