Healthcare Provider Details

I. General information

NPI: 1609974195
Provider Name (Legal Business Name): MARK S KRISTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HIGHWAY 12
HETTINGER ND
58639-7530
US

IV. Provider business mailing address

1000 HIGHWAY 12
HETTINGER ND
58639-7530
US

V. Phone/Fax

Practice location:
  • Phone: 701-567-4561
  • Fax: 701-567-6363
Mailing address:
  • Phone: 701-567-4561
  • Fax: 701-567-6363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number7219
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: