Basic Information
| Provider Information | |||||||||
| NPI: | 1053621045 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACHADO | ||||||||
| FirstName: | KERRY-ANNE | ||||||||
| MiddleName: | SHERIE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 DON WICKHAM DR | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525368840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 DON WICKHAM DR | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347111979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525368840 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2010 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT195051 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME1197742 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3810024703 | 05 | WV | MEDICAID |