Provider Demographics
NPI:1508907452
Name:CHONGSIRIWATANA, KRISTINA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:CHONGSIRIWATANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6320 RIVERSIDE PLAZA LN NW STE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1710
Mailing Address - Country:US
Mailing Address - Phone:505-843-6168
Mailing Address - Fax:505-792-1978
Practice Address - Street 1:4640 JEFFERSON LN NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2116
Practice Address - Country:US
Practice Address - Phone:505-843-6168
Practice Address - Fax:505-792-1978
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM2004-0276207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM86080261Medicaid
NMNM300781Medicare PIN