Basic Information
| Provider Information | |||||||||
| NPI: | 1922042738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KADERIS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8504754619 | ||||||||
| Practice Location | |||||||||
| Address1: | 5149 N 9TH AVE | ||||||||
| Address2: | SUITE 246 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504166159 | ||||||||
| FaxNumber: | 8504167198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | OS12384 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 010322300 | 05 | FL | MEDICAID |