MEDICARE: BLAINE S. KRISTO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	ME159017	FL
2	208800000X	Urology Physician	MD-13190	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0000253955	OTHER	HI	HMSA BILLING NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124128822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAINE S. KRISTO MD

Provider Business Mailing Address
First Line	:	PO BOX 746643
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6643
Country	:	US
Telephone Number	:	904-202-2092
Fax Number	:	904-376-4075

Provider Business Practice Location Address
First Line	:	1348 S 18TH ST STE 230
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-4785
Country	:	US
Telephone Number	:	904-277-2003
Fax Number	:	904-376-3271

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	11/04/2025

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Directions to “ BLAINE S. KRISTO MD” Practice Location

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