Healthcare Provider Details

I. General information

NPI: 1235758889
Provider Name (Legal Business Name): KRISTINA BLACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 01/10/2026
Certification Date: 01/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11260 SULLIVAN ST
RIVERVIEW FL
33578-2140
US

IV. Provider business mailing address

11260 SULLIVAN ST
RIVERVIEW FL
33578-2140
US

V. Phone/Fax

Practice location:
  • Phone: 813-689-7571
  • Fax:
Mailing address:
  • Phone: 813-689-7571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number95417
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.43174
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME168721
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: