Provider Demographics
NPI:1851719124
Name:TIBAVISKY, KRISTINE JENNY (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:JENNY
Last Name:TIBAVISKY
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 1:653-1 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:904-383-1037
Mailing Address - Fax:904-244-6656
Practice Address - Street 1:653-1 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-383-1037
Practice Address - Fax:904-244-6656
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME136019207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology