Provider Demographics
NPI:1881656841
Name:KRIZAN, KELLY JOE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JOE
Last Name:KRIZAN
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 1:3417 ENSIGN RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5064
Mailing Address - Country:US
Mailing Address - Phone:360-493-4600
Mailing Address - Fax:360-493-4603
Practice Address - Street 1:3417 ENSIGN RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5064
Practice Address - Country:US
Practice Address - Phone:360-493-4600
Practice Address - Fax:360-493-4603
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000242122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR207097Medicaid
ID807397800Medicaid
WA5995KROtherREGENCE BLUE SHIELD
WA8450025Medicaid
WAG8859251Medicare PIN
E71154Medicare UPIN
ID807397800Medicaid