Provider Demographics
NPI:1558890202
Name:ANDERSON, KRISTEN CELESTE (DO)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:CELESTE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11530 ALLISONVILLE RD STE 190
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-1862
Practice Address - Country:US
Practice Address - Phone:317-678-3850
Practice Address - Fax:317-222-2332
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-05350208000000X
IN02007663A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1101930299OtherANTHEM PTAN
IN264430I87OtherMEDICARE PTAN
IN300087483Medicaid