Provider Demographics
NPI:1124018510
Name:HAWORTH, KRISTINA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:MARIE
Last Name:HAWORTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:MARIE
Other - Last Name:LEGGITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1245 MADISON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1245 MADISON AVENUE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2222
Practice Address - Country:US
Practice Address - Phone:901-722-3395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 10079 TPL152W00000X
IDODP-898152W00000X
OR4023 T152W00000X
OH5757/T2671152W00000X
TN3259152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0100790Medicaid
CASD0100790Medicaid
CASD0100790Medicaid