Provider Demographics
NPI:1235120023
Name:MATTHEWIS, KRISTIANNA DOMINIQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIANNA
Middle Name:DOMINIQUE
Last Name:MATTHEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 N PINE RD
Mailing Address - Street 2:STE A
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-2159
Mailing Address - Country:US
Mailing Address - Phone:989-928-3566
Mailing Address - Fax:989-391-9596
Practice Address - Street 1:863 N PINE RD
Practice Address - Street 2:STE A
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732-2159
Practice Address - Country:US
Practice Address - Phone:989-928-3566
Practice Address - Fax:989-391-9596
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKM066182207Q00000X
MI4301066182207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4267386Medicaid
H30738OtherHAP
P00060645OtherPALMETTO
383569775OtherSHEAKLEY UNICOMB
0807800522OtherBCBSM
0807800522OtherBCBSM
P00060645OtherPALMETTO