Provider Demographics
NPI:1780874883
Name:GILES-MAGNIFICO, KRISTINA A (MD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:A
Last Name:GILES-MAGNIFICO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:A
Other - Last Name:GILES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:887 CONGRESS ST STE 400
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3163
Mailing Address - Country:US
Mailing Address - Phone:207-774-6368
Mailing Address - Fax:
Practice Address - Street 1:887 CONGRESS ST STE 400
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3163
Practice Address - Country:US
Practice Address - Phone:207-774-6368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232850208600000X
FLME1207372086S0129X
MEMD23932208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012882300Medicaid
FLHX167ZMedicare PIN