Provider Demographics
NPI:1366451411
Name:CASSIDY, KRISTIN K (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:K
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:150 LANCE DR
Practice Address - Street 2:
Practice Address - City:TWIN LAKES
Practice Address - State:WI
Practice Address - Zip Code:53181
Practice Address - Country:US
Practice Address - Phone:262-877-2124
Practice Address - Fax:262-877-9833
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40094207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34012400Medicaid
BC6072932OtherDEA NUMBER
BC6072932OtherDEA NUMBER