Provider Demographics
NPI:1053368043
Name:MAURICE, KETTY (DO)
Entity type:Individual
Prefix:DR
First Name:KETTY
Middle Name:
Last Name:MAURICE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:239-424-1479
Mailing Address - Fax:239-424-1423
Practice Address - Street 1:636 DEL PRADO BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2695
Practice Address - Country:US
Practice Address - Phone:239-424-3123
Practice Address - Fax:239-424-4041
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.2613207Q00000X
KY04090207Q00000X
FLOS8053207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26036830Medicaid
FLE5976Medicare ID - Type Unspecified
FLE5976Medicare PIN
FL26036830Medicaid