Provider Demographics
NPI:1497700223
Name:BLY, KRIS M (DO)
Entity Type:Individual
Prefix:DR
First Name:KRIS
Middle Name:M
Last Name:BLY
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 1:2777 ENTERPRISE RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8310
Mailing Address - Country:US
Mailing Address - Phone:386-774-2550
Mailing Address - Fax:386-774-5667
Practice Address - Street 1:2777 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8310
Practice Address - Country:US
Practice Address - Phone:386-774-2550
Practice Address - Fax:386-774-5667
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10451208D00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02001471BOtherCSR
FL17085OtherBCBSFL
IN02001471AOtherINDIANA LICENSE
FL0S10451OtherFLORIDA LICENCE
FL17085OtherBCBSFL
FLCN662XMedicare UPIN