Provider Demographics
NPI:1699707299
Name:KRIETT, JOLENE M (MD)
Entity type:Individual
Prefix:DR
First Name:JOLENE
Middle Name:M
Last Name:KRIETT
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 1:200 WEST ARBOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-8201
Mailing Address - Country:US
Mailing Address - Phone:619-543-7777
Mailing Address - Fax:619-543-3183
Practice Address - Street 1:200 WEST ARBOR DRIVE
Practice Address - Street 2:UCSD MEDICAL CENTER
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9001
Practice Address - Country:US
Practice Address - Phone:619-543-7777
Practice Address - Fax:619-543-3183
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67449208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G674490Medicaid
D81075Medicare UPIN
CAWG67449AMedicare ID - Type Unspecified