Provider Demographics
NPI:1922116763
Name:OLIVER, KRISTIN SUZANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:SUZANNE
Last Name:OLIVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:SUZANNE
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:17300 NORTH OUTER 40 RD STE 201
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1364
Mailing Address - Country:US
Mailing Address - Phone:636-778-2900
Mailing Address - Fax:636-778-2828
Practice Address - Street 1:2807 W BROADWAY STE 107
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-1317
Practice Address - Country:US
Practice Address - Phone:573-446-4000
Practice Address - Fax:636-778-2828
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69818-20207QS0010X
MO107123207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine