Provider Demographics
NPI:1992025985
Name:DIDOMENICO, KRISTIN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:DIDOMENICO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MARIE
Other - Last Name:DOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 WALNUT ST STE 210W
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3323
Mailing Address - Country:US
Mailing Address - Phone:215-925-6402
Mailing Address - Fax:215-925-0262
Practice Address - Street 1:601 WALNUT ST STE 210W
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3323
Practice Address - Country:US
Practice Address - Phone:215-925-6402
Practice Address - Fax:215-925-0262
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD451396207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology