Provider Demographics
NPI:1487622957
Name:MAHAN, KRISTIN A (MD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:A
Last Name:MAHAN
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 1:406 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1340
Mailing Address - Country:US
Mailing Address - Phone:812-882-1106
Mailing Address - Fax:812-885-2758
Practice Address - Street 1:406 N 1ST ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1340
Practice Address - Country:US
Practice Address - Phone:812-882-1106
Practice Address - Fax:812-895-2458
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053104A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200325700Medicaid
IN1224690001Medicare NSC
IN441910Medicare PIN
INM400032467Medicare PIN
INH33336Medicare UPIN
IN258190Medicare PIN
IN080183060Medicare PIN