Provider Demographics
NPI:1184315186
Name:KIZILBASH, KAMRAN (MD)
Entity type:Individual
Prefix:
First Name:KAMRAN
Middle Name:
Last Name:KIZILBASH
Suffix:
Gender:M
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 RETREAT AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3309
Mailing Address - Country:US
Mailing Address - Phone:860-545-7062
Mailing Address - Fax:
Practice Address - Street 1:409 MAPLE AVENUE-D2N
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-545-7062
Practice Address - Fax:860-545-7920
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT416952084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry