Provider Demographics
NPI:1023497815
Name:KRISTAL, ROSS (MD)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:KRISTAL
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 1:4415 34TH AVE APT 4C
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-1058
Mailing Address - Country:US
Mailing Address - Phone:954-292-8197
Mailing Address - Fax:
Practice Address - Street 1:545 E 142ND ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454
Practice Address - Country:US
Practice Address - Phone:844-692-4692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297825207R00000X
390200000X
CT60588207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program