Provider Demographics
NPI:1760801708
Name:SO, KRISTINE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:SO
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 1:4700 WATERS AVE
Mailing Address - Street 2:SURGICAL EDUCATION DEPARTMENT
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-8598
Mailing Address - Fax:912-350-5984
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:SURGICAL EDUCATION DEPARTMENT
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-8598
Practice Address - Fax:912-350-5984
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63514390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program