Provider Demographics
NPI:1891140984
Name:COMBS, KALLIE DESMOND (DO)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:DESMOND
Last Name:COMBS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KALLIE
Other - Middle Name:JOELLE
Other - Last Name:DESMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:56-44 MAIN STREET
Mailing Address - Street 2:C/O LILY HI
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5645 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:718-670-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299226207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine