Provider Demographics
NPI:1407174147
Name:CARSWELL, KRISTINA NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:NICOLE
Last Name:CARSWELL
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 1:115 COBBLESTONE LN
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8209
Mailing Address - Country:US
Mailing Address - Phone:843-449-1438
Mailing Address - Fax:843-286-1349
Practice Address - Street 1:406 46TH AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-2732
Practice Address - Country:US
Practice Address - Phone:478-397-0947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116618208000000X
GA85877208000000X
SCMD39717208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009265300Medicaid
FLHM580ZMedicare PIN