Provider Demographics
NPI:1154332054
Name:FAGERBERG, KRISTYN TIFFANY (MD)
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:TIFFANY
Last Name:FAGERBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTYN
Other - Middle Name:TIFFANY
Other - Last Name:HODES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-8800
Mailing Address - Fax:
Practice Address - Street 1:11805 FM 2244 RD STE 100
Practice Address - Street 2:
Practice Address - City:BEE CAVE
Practice Address - State:TX
Practice Address - Zip Code:78738-5337
Practice Address - Country:US
Practice Address - Phone:512-402-9013
Practice Address - Fax:512-402-9016
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL3294OtherLICENSE
TXL3294OtherLICENSE