Provider Demographics
NPI:1124128822
Name:KRISTO, BLAINE S (MD)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:S
Last Name:KRISTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746643
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6643
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:1348 S 18TH ST STE 230
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4785
Practice Address - Country:US
Practice Address - Phone:904-277-2003
Practice Address - Fax:904-277-2006
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-13190208800000X
FLME159017208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000253955OtherHMSA BILLING NUMBER
HI572702-01Medicaid
HI572702-01Medicaid
HIH100667Medicare PIN