Provider Demographics
NPI:1255826376
Name:COLLISTER, KRISTEN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:COLLISTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:608 STANTON L YOUNG BLVD # 509
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5014
Mailing Address - Country:US
Mailing Address - Phone:405-271-7816
Mailing Address - Fax:
Practice Address - Street 1:608 STANTON L YOUNG BLVD # 509
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5014
Practice Address - Country:US
Practice Address - Phone:405-271-7816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-30
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NETEP8298207R00000X
OK34604207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine