Provider Demographics
NPI:1346447174
Name:CARMODY, KRISTIN AYN (MD, MHPE)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:AYN
Last Name:CARMODY
Suffix:
Gender:F
Credentials:MD, MHPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PETER COOPER RD APT 14C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-6727
Mailing Address - Country:US
Mailing Address - Phone:917-783-2711
Mailing Address - Fax:
Practice Address - Street 1:2 PETER COOPER RD APT 14C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6727
Practice Address - Country:US
Practice Address - Phone:917-783-2711
Practice Address - Fax:616-975-9824
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045259207P00000X
MA235229207P00000X
NY241810207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2159325Medicaid
MA2159325Medicaid