Provider Demographics
NPI:1902978497
Name:KEVIN M LYNCH DPM PA
Entity Type:Organization
Organization Name:KEVIN M LYNCH DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:321-454-6333
Mailing Address - Street 1:260 FORTENBERRY RD
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3619
Mailing Address - Country:US
Mailing Address - Phone:321-454-6333
Mailing Address - Fax:321-454-9877
Practice Address - Street 1:260 FORTENBERRY RD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3619
Practice Address - Country:US
Practice Address - Phone:321-454-6333
Practice Address - Fax:321-454-9877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2478213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390231500Medicaid
FL65363Medicare ID - Type Unspecified
FL0955020001Medicare NSC
FL390231500Medicaid