Provider Demographics
NPI:1114158813
Name:DIMITRIS, KRISTEN MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:DIMITRIS
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 1:5400 FRANTZ RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 POLARIS PKWY
Practice Address - Street 2:SUITE 2150
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7989
Practice Address - Country:US
Practice Address - Phone:614-533-3280
Practice Address - Fax:614-533-3289
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35095745207Q00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0068478Medicaid
OHH098720Medicare PIN