Provider Demographics
NPI:1043328735
Name:KINNE, SANDFORD H III (DO)
Entity type:Individual
Prefix:DR
First Name:SANDFORD
Middle Name:H
Last Name:KINNE
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 731869
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32173-1869
Mailing Address - Country:US
Mailing Address - Phone:386-677-5600
Mailing Address - Fax:386-677-5686
Practice Address - Street 1:290 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE A-1
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-677-5600
Practice Address - Fax:386-677-5686
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013379100Medicaid
FL58722OtherAETNA
FL593573926OtherTRICARE HUMANA
FL80893Medicare ID - Type Unspecified
FL013379100Medicaid