Provider Demographics
NPI:1295729267
Name:GREGORY, KRISTYN MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:KRISTYN
Middle Name:MARIE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16075 WHITE WATER DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-6183
Mailing Address - Country:US
Mailing Address - Phone:586-203-2020
Mailing Address - Fax:810-794-7751
Practice Address - Street 1:57327 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48094-2892
Practice Address - Country:US
Practice Address - Phone:586-203-2020
Practice Address - Fax:586-992-1210
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010145612084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2655012874OtherBCBSM
MI20-8324146OtherTAX ID