Provider Demographics
NPI:1356473144
Name:ONTIVEROS, KRISTY R (MD)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:R
Last Name:ONTIVEROS
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:PO BOX 5719
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-5719
Mailing Address - Country:US
Mailing Address - Phone:706-354-5770
Mailing Address - Fax:706-354-5769
Practice Address - Street 1:2450 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5069
Practice Address - Country:US
Practice Address - Phone:706-354-5770
Practice Address - Fax:706-354-5769
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0521207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM 30571880Medicaid
NM343603201Medicare PIN