Provider Demographics
NPI:1427546811
Name:WEIDERT, KRISTIN ANNE (DO)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANNE
Last Name:WEIDERT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:ANNE
Other - Last Name:GIBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-349-6560
Mailing Address - Fax:517-349-5796
Practice Address - Street 1:1600 W GRAND RIVER AVE STE 2
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2394
Practice Address - Country:US
Practice Address - Phone:517-349-6560
Practice Address - Fax:517-349-5796
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101025661208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics