Provider Demographics
NPI:1083920383
Name:CALLISTE, INGRID KISHA NIDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:KISHA NIDRA
Last Name:CALLISTE
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 1:13900 CR 455, SUITE 107, #373
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-9029
Mailing Address - Country:US
Mailing Address - Phone:352-385-7718
Mailing Address - Fax:
Practice Address - Street 1:1865 NIGHTINGALE LN STE A
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4360
Practice Address - Country:US
Practice Address - Phone:352-385-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135623207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program