Provider Demographics
NPI:1114005501
Name:POLLER, KRISTINA JEAN (DO)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:JEAN
Last Name:POLLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:JEAN
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:8008 WESTPARK DR
Practice Address - Street 2:KAISER PERMANENTE TYSONS CORNER MEDICAL CENTER
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3109
Practice Address - Country:US
Practice Address - Phone:703-287-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0069445207L00000X
VA0102202776207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD418033000Medicaid
MD159781ZEDOMedicare PIN