Provider Demographics
NPI:1538489869
Name:HOUSEKNECHT, KRISTIN W (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:W
Last Name:HOUSEKNECHT
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 1:323 E WACKER DR
Mailing Address - Street 2:#118
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5282
Mailing Address - Country:US
Mailing Address - Phone:813-495-2785
Mailing Address - Fax:
Practice Address - Street 1:1225 E COOLSPRING AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-6312
Practice Address - Country:US
Practice Address - Phone:219-873-2919
Practice Address - Fax:219-873-2909
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN14997390200000X
FLME108909208D00000X
IL125.0879112085R0001X
IN01077086A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001052783OtherANTHEM
IN201398420Medicaid
IN201398420Medicaid