Healthcare Provider Details

I. General information

NPI: 1720420748
Provider Name (Legal Business Name): KRISTIN RUTH TOLIVER D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN TOLIVER D.P.M.

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 LAKE AVE
FORT WAYNE IN
46805-5100
US

IV. Provider business mailing address

2121 LAKE AVE
FORT WAYNE IN
46805-5100
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-5431
  • Fax:
Mailing address:
  • Phone: 260-426-5431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001259A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: