Healthcare Provider Details

I. General information

NPI: 1811941768
Provider Name (Legal Business Name): KEVIN R KRISTL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14404 STATE ROAD 23 STE B
GRANGER IN
46530-7778
US

IV. Provider business mailing address

14404 STATE ROAD 23 STE B
GRANGER IN
46530-7778
US

V. Phone/Fax

Practice location:
  • Phone: 574-252-7795
  • Fax: 574-252-7796
Mailing address:
  • Phone: 574-252-7795
  • Fax: 574-252-7796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01037448
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: