Provider Demographics
NPI:1811151780
Name:HARTLAGE, KIERSTEN RIAL (MD)
Entity type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:RIAL
Last Name:HARTLAGE
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 1:4033 TAMPA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3224
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-855-2367
Practice Address - Street 1:5259 VILLAGE MARKET
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544
Practice Address - Country:US
Practice Address - Phone:813-973-0333
Practice Address - Fax:813-973-2313
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106588208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003808200Medicaid
FLFG454ZMedicare PIN