Provider Demographics
NPI:1659534410
Name:VINE, KATHLEEN ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ROSE
Last Name:VINE
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 1:200 E 15TH ST APT 10C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3960
Mailing Address - Country:US
Mailing Address - Phone:646-418-6584
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY
Practice Address - Street 2:SUITE 301
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6008
Practice Address - Country:US
Practice Address - Phone:646-421-6064
Practice Address - Fax:646-843-4701
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262895207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology