Provider Demographics
NPI:1619936945
Name:DAVIS, KRISTY K (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:K
Last Name:DAVIS
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:13813 METRO PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4343
Practice Address - Country:US
Practice Address - Phone:239-936-1343
Practice Address - Fax:239-936-8507
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16295207Q00000X
MI5101009027207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI113418332Medicaid
MIE33142Medicare UPIN
OP53180Medicare PIN
MI0G56212019Medicare PIN