Provider Demographics
NPI:1689801748
Name:MACOMBER, KRISTINE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:MACOMBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:PATTISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:345 N MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2515
Mailing Address - Country:US
Mailing Address - Phone:860-561-7222
Mailing Address - Fax:860-561-7228
Practice Address - Street 1:345 N MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2515
Practice Address - Country:US
Practice Address - Phone:860-561-7222
Practice Address - Fax:860-561-7228
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT052014207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT052014OtherLICENSE