Provider Demographics
NPI:1295960631
Name:TIMMERMAN, KRISTA DAVENPORT (MD)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:DAVENPORT
Last Name:TIMMERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:JOYCE
Other - Last Name:DAVENPORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:1210 W FARIS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4444
Practice Address - Country:US
Practice Address - Phone:864-522-1800
Practice Address - Fax:864-522-1806
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC378792085R0202X, 2085R0202X
FLME1207412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012439500Medicaid
FL012439500Medicaid