Provider Demographics
NPI:1508891243
Name:KRISS, DEBORAH LEADHOLM (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEADHOLM
Last Name:KRISS
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 1:553 CLINTON AVE
Mailing Address - Street 2:KOINONIA HEALTH CARE
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206
Mailing Address - Country:US
Mailing Address - Phone:518-689-0282
Mailing Address - Fax:518-689-0283
Practice Address - Street 1:553 CLINTON AVE
Practice Address - Street 2:KOINONIA HEALTH CARE
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-2738
Practice Address - Country:US
Practice Address - Phone:518-689-0282
Practice Address - Fax:518-689-0283
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60-1397072080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000472214006OtherBSNENY
NY5331692OtherAETNA
NY10022210OtherCDPHP
NY010ZM1OtherEMPIRE BLUECROSS
NY3007738OtherMVP HEALTHCARE
090406000031OtherFIDELIS
NY137306OtherGHI/HMO
NY137306OtherGHI/HMO