Provider Demographics
NPI:1003074071
Name:BRESOWAR, KRISTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:
Last Name:BRESOWAR
Suffix:
Gender:F
Credentials:MD
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 729
Mailing Address - Street 2:
Mailing Address - City:SALTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24370-0729
Mailing Address - Country:US
Mailing Address - Phone:276-496-4433
Mailing Address - Fax:276-496-5923
Practice Address - Street 1:308 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALTVILLE
Practice Address - State:VA
Practice Address - Zip Code:24370-3112
Practice Address - Country:US
Practice Address - Phone:276-496-4433
Practice Address - Fax:276-496-5923
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101255920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1952434383Medicaid
COCOAAA2568Medicare PIN