Provider Demographics
NPI:1235174731
Name:PELLICORE, KRISTA DEANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:DEANN
Last Name:PELLICORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3101 N CENTRAL AVE STE 550
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2635
Mailing Address - Country:US
Mailing Address - Phone:602-230-7373
Mailing Address - Fax:602-682-7455
Practice Address - Street 1:235 W WESTERN AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1848
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:602-230-3086
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48328207Q00000X
IN01057388A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200447730Medicaid
000000305690OtherBCBS PROVIDER NUMBER
AZ857797Medicaid
H93046Medicare UPIN
IN200447730Medicaid