Healthcare Provider Details

I. General information

NPI: 1093881567
Provider Name (Legal Business Name): KRISTINA REA BLACK KRATOVIL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINA REA BLACK M.D.

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 BOONE BLVD STE 500
VIENNA VA
22182-2681
US

IV. Provider business mailing address

109 STATE ST STE 5
BOSTON MA
02109-2906
US

V. Phone/Fax

Practice location:
  • Phone: 617-505-1520
  • Fax: 617-928-8401
Mailing address:
  • Phone: 617-505-1520
  • Fax: 617-928-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101240416
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2025-01557
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number0101240416
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01081902A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: