Provider Demographics
NPI:1982924502
Name:CONLON, KRISTY MICHELLE (DO)
Entity type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:MICHELLE
Last Name:CONLON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:MICHELLE
Other - Last Name:WIEBKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:836 E. 65TH STREET
Mailing Address - Street 2:SUITE 22
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-819-7878
Mailing Address - Fax:912-819-3320
Practice Address - Street 1:11909 MCAULEY DRIVE
Practice Address - Street 2:BLDG 100 A2
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419
Practice Address - Country:US
Practice Address - Phone:912-354-8331
Practice Address - Fax:912-352-9782
Is Sole Proprietor?:No
Enumeration Date:2010-06-05
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO2440208600000X
GA788502086S0129X
LADO000449208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003194369AMedicaid