Provider Demographics
NPI:1164435590
Name:KATKAVICH, KRISTIE (OD)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:KATKAVICH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2014
Mailing Address - Country:US
Mailing Address - Phone:860-423-2111
Mailing Address - Fax:860-423-7559
Practice Address - Street 1:1120 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2014
Practice Address - Country:US
Practice Address - Phone:860-423-2111
Practice Address - Fax:860-423-7559
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002698152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist