Provider Demographics
NPI:1992836290
Name:BURRIS, KRISTA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:LYNN
Last Name:BURRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KRISTA
Other - Middle Name:BURRIS
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:72780 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4150
Mailing Address - Country:US
Mailing Address - Phone:760-674-3847
Mailing Address - Fax:760-674-3845
Practice Address - Street 1:72780 COUNTRY CLUB DR
Practice Address - Street 2:SUITE 203
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4150
Practice Address - Country:US
Practice Address - Phone:760-674-3847
Practice Address - Fax:760-674-3845
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA068708207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH51775Medicare UPIN