Basic Information
| Provider Information | |||||||||
| NPI: | 1124066238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIERSTEAD | ||||||||
| FirstName: | BETTY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 976 MCLEAN AVE | ||||||||
| Address2: | SUITE 387 | ||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107044105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142376797 | ||||||||
| FaxNumber: | 9142064950 | ||||||||
| Practice Location | |||||||||
| Address1: | 976 MCLEAN AVE | ||||||||
| Address2: | SUITE 387 | ||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107044105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142376797 | ||||||||
| FaxNumber: | 9142064950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME92188 | MD | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | ME92188 | 01 | FL | MEDICAL LICENSE | OTHER |