Healthcare Provider Details

I. General information

NPI: 1720353428
Provider Name (Legal Business Name): KRISTEN N WITHAM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 COSHOCTON AVE
MOUNT VERNON OH
43050
US

IV. Provider business mailing address

1330 COSHOCTON AVE
MOUNT VERNON OH
43050
US

V. Phone/Fax

Practice location:
  • Phone: 740-393-9000
  • Fax: 740-392-0167
Mailing address:
  • Phone: 740-393-9000
  • Fax: 740-392-0167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number58004610
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number34.012397
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: