Provider Demographics
NPI:1477849149
Name:DEITCHMAN, KRISTEN SHAW (DO)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:SHAW
Last Name:DEITCHMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ELIZABETH
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4924 CAMPBELL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-5908
Mailing Address - Country:US
Mailing Address - Phone:443-442-2300
Mailing Address - Fax:410-367-2035
Practice Address - Street 1:4924 CAMPBELL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-5908
Practice Address - Country:US
Practice Address - Phone:443-442-2300
Practice Address - Fax:410-367-2035
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0081342208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics