Provider Demographics
NPI:1417538323
Name:BURRIDGE, KRISTA LEE (MD)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:LEE
Last Name:BURRIDGE
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 1:4101 EDWARDS RD FL 2
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-1678
Mailing Address - Country:US
Mailing Address - Phone:513-981-4646
Mailing Address - Fax:513-979-2830
Practice Address - Street 1:4101 EDWARDS RD FL 2
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-1678
Practice Address - Country:US
Practice Address - Phone:513-981-4646
Practice Address - Fax:513-979-2830
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT222289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMT222289OtherGRADUATE MEDICAL TRAINEE LICENSE NUMBER