Provider Demographics
NPI:1316944358
Name:KRISTENSEN, JOHN W (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:KRISTENSEN
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 1:165 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RAYMONDVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78580-3521
Mailing Address - Country:US
Mailing Address - Phone:956-689-5506
Mailing Address - Fax:956-689-1988
Practice Address - Street 1:165 S 6TH ST
Practice Address - Street 2:
Practice Address - City:RAYMONDVILLE
Practice Address - State:TX
Practice Address - Zip Code:78580-3521
Practice Address - Country:US
Practice Address - Phone:956-689-5506
Practice Address - Fax:956-689-1988
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2008-06-13
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
TXG2414207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0000047206501OtherUNITED HEALTHCARE
TX121472802Medicaid
TX00SH91OtherBC/BS OF TEXAS
TX110005062OtherRAILROAD MEDICARE
TX742591908OtherTRICARE (PGBA)
TX135937100OtherVALLEY BAPTIST HEALTH PLANS
TX4357806OtherAETNA
TX2869048P01OtherCIGNA
TX4357806OtherAETNA
TXB24120Medicare UPIN
TX2869048P01OtherCIGNA
TX00SH91Medicare ID - Type Unspecified