Basic Information
| Provider Information | |||||||||
| NPI: | 1306023593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINDSTROM | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | D'ACO | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331814 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1920 E CAMBRIDGE AVE STE 304 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850061464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029334363 | ||||||||
| FaxNumber: | 6029332415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 03/23/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0201X | 264846 | NY | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 208000000X | 264846 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 046719 | CT | N | Allopathic & Osteopathic Physicians | Pediatrics | 207SG0201X | 49590 | AZ | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
ID Information
| ID | Type | State | Issuer | Description | 03463421 | 05 | NY | MEDICAID |