Provider Demographics
NPI:1811941768
Name:KRISTL, KEVIN R (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:KRISTL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 E DAY RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-4300
Mailing Address - Country:US
Mailing Address - Phone:574-252-7795
Mailing Address - Fax:574-252-7796
Practice Address - Street 1:1710 E DAY RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-4300
Practice Address - Country:US
Practice Address - Phone:574-252-7795
Practice Address - Fax:574-252-7796
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010374482084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1336414499Medicaid
IN100179640Medicaid