Individual
DR. KYLE HAVERSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
11200 SEMINOLE BLVD STE 305, LARGO, FL 33778-3239
(727) 431-9552
(727) 290-4376
Mailing address
15815 SHADDOCK DR STE 130, WINTER GARDEN, FL 34787-5773
(813) 400-1140
(813) 701-9132
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
PO4312
FL
213EP1101X
Primary Podiatric Medicine Podiatrist
PO4312
FL
213ES0000X
Sports Medicine Podiatrist
PO4312
FL
213ES0103X
Foot & Ankle Surgery Podiatrist
PO4312
FL
213ES0131X
Foot Surgery Podiatrist
PO4312
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
111187000
—
FL
01
—
14929205
CAQH ID
—
01
—
5G5CI
BCBS
FL
Enumeration date
07/03/2017
Last updated
03/10/2025
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