Provider Demographics
NPI:1033616909
Name:WAISANEN, KYLE MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MATTHEW
Last Name:WAISANEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-968-9303
Mailing Address - Fax:239-396-8932
Practice Address - Street 1:8931 COLONIAL CENTER DR STE 401
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7809
Practice Address - Country:US
Practice Address - Phone:239-396-8930
Practice Address - Fax:239-396-8932
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME162353208800000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118384100Medicaid