Provider Demographics
NPI:1629074752
Name:KRZYSTOLIK, MAGDALENA G (MD)
Entity Type:Individual
Prefix:DR
First Name:MAGDALENA
Middle Name:G
Last Name:KRZYSTOLIK
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 1:1 RANDALL SQ
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2709
Mailing Address - Country:US
Mailing Address - Phone:401-453-4600
Mailing Address - Fax:401-453-0077
Practice Address - Street 1:1 RANDALL SQ
Practice Address - Street 2:SUITE 203
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2709
Practice Address - Country:US
Practice Address - Phone:401-453-4600
Practice Address - Fax:401-453-0077
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153331207W00000X
RIMD10368207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3165361Medicaid
RI7008397Medicaid
RI7008397Medicaid
MAM21796Medicare PIN
RI189004676Medicare PIN