Provider Demographics
NPI:1194758219
Name:KRESHAK, ALLYSON A (MD)
Entity type:Individual
Prefix:
First Name:ALLYSON
Middle Name:A
Last Name:KRESHAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W ARBOR DR
Mailing Address - Street 2:MAILCODE 8925
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-9001
Mailing Address - Country:US
Mailing Address - Phone:267-872-3916
Mailing Address - Fax:858-715-6361
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:MAILCODE 8925
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9001
Practice Address - Country:US
Practice Address - Phone:267-872-3916
Practice Address - Fax:858-715-6361
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD13560207P00000X
CAA102811207PT0002X, 207P00000X
PAMD424637207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101658673Medicaid
CA1194758219Medicaid
NJ0107375Medicaid
RI939025129OtherRI MEDICARE GROUP
CA1194758219Medicaid
CAAQ253ZMedicare PIN
RI939025129OtherRI MEDICARE GROUP