Provider Demographics
NPI:1376530618
Name:CLEMONS, KRISTIN E (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:E
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:E
Other - Last Name:LELVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1317 EDGEWATER DR # 2945
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6350
Mailing Address - Country:US
Mailing Address - Phone:407-538-5921
Mailing Address - Fax:
Practice Address - Street 1:1201 OAKBRIDGE PKWY
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-5945
Practice Address - Country:US
Practice Address - Phone:863-279-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI079600208100000X
WI52430208100000X
FLME137481208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101476800Medicaid
MI4396267Medicaid
WIP00772226CD3624OtherRR MEDICARE
MI250E26047OtherBLUE CROSS BLUE SHIELD MI
WILELVIKRIOtherMERCYCARE INSURANCE
MI250E26047OtherBLUE CROSS BLUE SHIELD MI
MI4396267Medicaid
WI541760607Medicare PIN