Provider Demographics
NPI:1396764460
Name:WITFILL, KRISTIN J
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:J
Last Name:WITFILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:J
Other - Last Name:WITFILL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:8220 US19 NORTH
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668
Mailing Address - Country:US
Mailing Address - Phone:727-841-8505
Mailing Address - Fax:727-846-0561
Practice Address - Street 1:8220 US19 NORTH
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668
Practice Address - Country:US
Practice Address - Phone:727-841-8505
Practice Address - Fax:727-846-0561
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL059398207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276890900Medicaid
U8190ZMedicare UPIN