Provider Demographics
NPI:1790760841
Name:KRIST, KEITH MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:MICHAEL
Last Name:KRIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:PEDIATRIC DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547
Mailing Address - Country:US
Mailing Address - Phone:850-863-8203
Mailing Address - Fax:850-862-0977
Practice Address - Street 1:1005 MAR WALT DRIVE
Practice Address - Street 2:PEDIATRIC DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-863-8203
Practice Address - Fax:850-862-0977
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85707208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265080100Medicaid
FL51445OtherBCBSFL
H67863Medicare UPIN
FL51445OtherBCBSFL