Healthcare Provider Details

I. General information

NPI: 1114381118
Provider Name (Legal Business Name): KRISTOPHER JACQUES PAULTRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13707 SW 152ND ST
MIAMI FL
33177-1106
US

IV. Provider business mailing address

1111 SW 1ST AVE APT 2620
MIAMI FL
33130-5408
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-9200
  • Fax:
Mailing address:
  • Phone: 954-732-8726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME137411
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberME137411
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: