Provider Demographics
NPI:1114174711
Name:OATES, KRISTINE M (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:OATES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:K
Other - Middle Name:MICHELLE
Other - Last Name:OATES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-5300
Mailing Address - Fax:801-387-5335
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:STE. A700
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-5300
Practice Address - Fax:801-387-5335
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7078644-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1114174711Medicaid
UT1114174711Medicaid