Basic Information
| Provider Information | |||||||||
| NPI: | 1023334976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STELTON | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | DUCKWORTH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUCKWORTH | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | BEATRIZ | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3093 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334310993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417457311 | ||||||||
| FaxNumber: | 9417457903 | ||||||||
| Practice Location | |||||||||
| Address1: | 446 TAMIAMI TRL S | ||||||||
| Address2: | #2 | ||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342852630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414833319 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2010 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME126862 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 017044900 | 05 | FL | MEDICAID |