Provider Demographics
NPI:1962606566
Name:BLANK, KRISTIE LISKA (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTIE
Middle Name:LISKA
Last Name:BLANK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7610 N STEMMONS FWY STE 600
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4228
Mailing Address - Country:US
Mailing Address - Phone:214-689-5960
Mailing Address - Fax:469-713-8084
Practice Address - Street 1:3144 HORIZON RD STE 210
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032
Practice Address - Country:US
Practice Address - Phone:972-771-2222
Practice Address - Fax:972-771-3350
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6531207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CY616OtherBCBSTX
TXP00467137OtherRR MCR PTAN
TX1885543-02Medicaid
TXP00467137OtherRR MCR PTAN
TX8CY616OtherBCBSTX
TXCI5830Medicare PIN
TXTXB139553Medicare PIN
TX1885543-02Medicaid
TX8K0211Medicare PIN