Provider Demographics
NPI:1467565192
Name:DETTLOFF, KRISTINE ADELL (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:ADELL
Last Name:DETTLOFF
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 1:4850 CHEVY CHASE DR
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-6420
Mailing Address - Country:US
Mailing Address - Phone:301-801-3867
Mailing Address - Fax:
Practice Address - Street 1:2041 GEORGIA AVE NW STE 1R84
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060-4000
Practice Address - Country:US
Practice Address - Phone:202-865-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD70505882085R0202X
DCMD0377152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC186969YA36Medicare UPIN