Provider Demographics
NPI:1235758889
Name:BLACK, KRISTINA (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HOWELL MILL RD NW STE 550
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-3099
Mailing Address - Country:US
Mailing Address - Phone:404-756-1400
Mailing Address - Fax:
Practice Address - Street 1:1800 HOWELL MILL RD NW STE 550
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-3099
Practice Address - Country:US
Practice Address - Phone:404-756-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA95417208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program