Provider Demographics
NPI:1245627926
Name:CHRISTOPHERSON, KAITLIN (MD)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:CHRISTOPHERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2134
Mailing Address - Country:US
Mailing Address - Phone:321-841-8650
Mailing Address - Fax:321-841-3794
Practice Address - Street 1:1400 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2134
Practice Address - Country:US
Practice Address - Phone:321-841-8650
Practice Address - Fax:321-841-3794
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1451312085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106139400Medicaid