Basic Information
| Provider Information | |||||||||
| NPI: | 1780689471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ESTRADA | ||||||||
| FirstName: | CRISTINA | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 609 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261430609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042753301 | ||||||||
| FaxNumber: | 3042754798 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 ELIZABETH PIKE | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042753301 | ||||||||
| FaxNumber: | 3042754798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 03/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16045 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0106689000 | 05 | WV | MEDICAID | 2389884 | 05 | OH | MEDICAID |