Provider Demographics
NPI:1194915421
Name:MIRE, KRISTINA MARIA (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:MARIA
Last Name:MIRE
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 1:4 BEGONIA DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-9100
Mailing Address - Country:US
Mailing Address - Phone:504-228-3406
Mailing Address - Fax:
Practice Address - Street 1:4 BEGONIA DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-9100
Practice Address - Country:US
Practice Address - Phone:504-228-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA339927208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1508331Medicaid