Provider Demographics
NPI:1003827056
Name:NESBURN, KRISTIN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:NESBURN
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 1:8635 W 3RD STREET
Mailing Address - Street 2:#390W
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-6101
Mailing Address - Country:US
Mailing Address - Phone:310-652-1133
Mailing Address - Fax:310-652-4353
Practice Address - Street 1:8635 W 3RD STREET
Practice Address - Street 2:#390W
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6101
Practice Address - Country:US
Practice Address - Phone:310-652-1133
Practice Address - Fax:310-652-4353
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60925207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A609250Medicaid
H04800Medicare UPIN
CA00A609250Medicaid