Provider Demographics
NPI:1356554216
Name:DEMOCK, KRISTI LYNN (DO)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:LYNN
Last Name:DEMOCK
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 1:107 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SARANAC
Mailing Address - State:MI
Mailing Address - Zip Code:48881-5121
Mailing Address - Country:US
Mailing Address - Phone:616-642-9408
Mailing Address - Fax:616-642-6940
Practice Address - Street 1:107 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SARANAC
Practice Address - State:MI
Practice Address - Zip Code:48881
Practice Address - Country:US
Practice Address - Phone:616-642-9408
Practice Address - Fax:616-642-6940
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI510101841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D16321049Medicare PIN