Healthcare Provider Details

I. General information

NPI: 1366538860
Provider Name (Legal Business Name): KRISTINA RAE VANDER MARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

22255 GREENFIELD RD STE 352
SOUTHFIELD MI
48075-3712
US

V. Phone/Fax

Practice location:
  • Phone: 863-284-6860
  • Fax:
Mailing address:
  • Phone: 248-849-3401
  • Fax: 248-849-4106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301076692
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number4301076692
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number4301076692
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME170074
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: