Provider Demographics
NPI:1063666352
Name:POTTER-MARTINO, KRISTINA R (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:R
Last Name:POTTER-MARTINO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KRISTINA
Other - Middle Name:R
Other - Last Name:MARTINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4601 DALE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9718
Mailing Address - Country:US
Mailing Address - Phone:209-735-5000
Mailing Address - Fax:
Practice Address - Street 1:3401 E DEBAZAN AVE
Practice Address - Street 2:
Practice Address - City:ST PETE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33706-4065
Practice Address - Country:US
Practice Address - Phone:813-244-1179
Practice Address - Fax:586-349-6022
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.010629207P00000X
FLOS12423207P00000X
MI5101018039207P00000X
CA16150207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty