Provider Demographics
NPI:1538154547
Name:KINI, VIDYA P (MD)
Entity type:Individual
Prefix:
First Name:VIDYA
Middle Name:P
Last Name:KINI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 MATTHEW DR 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1734
Mailing Address - Country:US
Mailing Address - Phone:239-274-5464
Mailing Address - Fax:239-275-5464
Practice Address - Street 1:3033 WINKLER AVE UNIT 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-9523
Practice Address - Country:US
Practice Address - Phone:239-277-7070
Practice Address - Fax:239-277-7071
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56122208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036091100Medicaid
FL036091100Medicaid
FLE22643Medicare UPIN