Provider Demographics
NPI:1477931236
Name:MCCAW, KRISTINA JHEANELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:JHEANELLE
Last Name:MCCAW
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 1:720 WESTVIEW DRIVE, SW
Mailing Address - Street 2:MOREHOUSE SCHOOL OF MEDICINE, DEPARTMENT OF INTERNAL ME
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310
Mailing Address - Country:US
Mailing Address - Phone:404-756-1325
Mailing Address - Fax:404-756-1313
Practice Address - Street 1:720 WESTVIEW DRIVE, SW
Practice Address - Street 2:MOREHOUSE SCHOOL OF MEDICINE, DEPARTMENT OF INTERNAL ME
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310
Practice Address - Country:US
Practice Address - Phone:404-756-1325
Practice Address - Fax:404-756-1313
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2019-09-03
Deactivation Date:2015-12-21
Deactivation Code:
Reactivation Date:2015-12-29
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA079271207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program