Provider Demographics
NPI:1417939661
Name:BROWN, KRISTY KEDIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:KEDIAN
Last Name:BROWN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:MASHPEE
Mailing Address - State:MA
Mailing Address - Zip Code:02649-6507
Mailing Address - Country:US
Mailing Address - Phone:508-477-7090
Mailing Address - Fax:508-477-7028
Practice Address - Street 1:107 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-6507
Practice Address - Country:US
Practice Address - Phone:508-477-7090
Practice Address - Fax:508-477-7028
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223219207Q00000X
MI5101017130207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2107465Medicaid
MA2107465Medicaid
MII38827Medicare UPIN
MAKE A39025Medicare ID - Type Unspecified