Provider Demographics
NPI:1801886866
Name:SELLBERG, KRISTINE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:
Last Name:SELLBERG
Suffix:
Gender:F
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:P.O. BOX 52886
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072
Mailing Address - Country:US
Mailing Address - Phone:602-298-7777
Mailing Address - Fax:623-930-6060
Practice Address - Street 1:5859 W TALAVI BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306
Practice Address - Country:US
Practice Address - Phone:602-298-7777
Practice Address - Fax:623-930-6060
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29043207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ972803Medicaid
AZ972803Medicaid
AZZ106270Medicare PIN