Provider Demographics
NPI:1164446829
Name:GROSKOPP, KRISTINE A (DO)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:A
Last Name:GROSKOPP
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 DOCTORS PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8127
Mailing Address - Country:US
Mailing Address - Phone:541-282-2200
Mailing Address - Fax:541-282-2237
Practice Address - Street 1:800 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7134
Practice Address - Country:US
Practice Address - Phone:541-608-7683
Practice Address - Fax:541-608-7689
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO15154207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR149484Medicaid
ORR105056Medicare PIN
OR149484Medicaid