Provider Demographics
NPI:1174515118
Name:GREENIDGE, KEVIN CECIL (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:CECIL
Last Name:GREENIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 WALNUT ST # 15512
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-3443
Mailing Address - Country:US
Mailing Address - Phone:727-432-3020
Mailing Address - Fax:
Practice Address - Street 1:200 BLOSSOM ST
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4204
Practice Address - Country:US
Practice Address - Phone:409-772-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93458207W00000X, 207WX0009X
MDD88314207WX0009X
TXU1430207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273351000Medicaid
28734ZMedicare PIN
FL273351000Medicaid