Provider Demographics
NPI:1609130566
Name:DRAKE, KRISTIN HARRIS (DO)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:HARRIS
Last Name:DRAKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LEIGH
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:645 N HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-2709
Mailing Address - Country:US
Mailing Address - Phone:314-749-8004
Mailing Address - Fax:
Practice Address - Street 1:3655 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:142-575-5553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180341652085R0202X
IL1250619182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology