Provider Demographics
NPI:1043657919
Name:TIEDT, KRISTIN ALLISON (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:ALLISON
Last Name:TIEDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:ALLISON
Other - Last Name:SPROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RI 3004
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-948-2700
Practice Address - Fax:317-948-2959
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076626208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201169230Medicaid
IN201169230Medicaid