Provider Demographics
NPI:1972786101
Name:KRISTY WHELAN D O P C
Entity Type:Organization
Organization Name:KRISTY WHELAN D O P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-680-3388
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-0645
Mailing Address - Country:US
Mailing Address - Phone:908-680-4233
Mailing Address - Fax:928-680-6522
Practice Address - Street 1:2082 MESQUITE AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6710
Practice Address - Country:US
Practice Address - Phone:908-680-4233
Practice Address - Fax:928-680-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE9062OtherRAILROAD MEDICARE
AZ701632001Medicaid
ZC9409OtherHEALTH NET
AZ0422120OtherBCBS AZ
Z108996Medicare PIN
AZ0422120OtherBCBS AZ