Provider Demographics
NPI:1629028832
Name:PROUD, CHRISTINA (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:PROUD
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:PO BOX 490210
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-0210
Mailing Address - Country:US
Mailing Address - Phone:800-778-6623
Mailing Address - Fax:
Practice Address - Street 1:8404 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-4016
Practice Address - Country:US
Practice Address - Phone:352-351-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0078846207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17236OtherBLUE SHIELD PROV NUMBER
FLBP6489543OtherFL DEA LICENSE NUMBER
FL17236OtherBLUE SHIELD PROV NUMBER
FLBP6489543OtherFL DEA LICENSE NUMBER
FLP00003903Medicare ID - Type UnspecifiedRR MEDICARE PROV NUMBER