Provider Demographics
NPI:1245761642
Name:BIRDSALL, KRISTINE FAULKNHAM (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:FAULKNHAM
Last Name:BIRDSALL
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 1:1025 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4223
Mailing Address - Country:US
Mailing Address - Phone:860-696-2400
Mailing Address - Fax:860-972-7040
Practice Address - Street 1:1025 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-4223
Practice Address - Country:US
Practice Address - Phone:860-696-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2022-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT69016207Q00000X
NY303175207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine