Provider Demographics
NPI:1144239054
Name:JENSEN, KRISTOPHER L (MD)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:L
Last Name:JENSEN
Suffix:
Gender:M
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:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:435 COMMERCIAL CT UNIT 300
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-1667
Practice Address - Country:US
Practice Address - Phone:941-261-0010
Practice Address - Fax:941-261-0011
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420009208207Q00000X
FLME140656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01868666Medicaid
VTOVN1785Medicaid
VTJEVN1785Medicare ID - Type Unspecified
NY01868666Medicaid