Provider Demographics
NPI:1720303985
Name:CHAMBERS, KYLE JACOB (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JACOB
Last Name:CHAMBERS
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 1:988 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4227
Mailing Address - Country:US
Mailing Address - Phone:860-493-1950
Mailing Address - Fax:860-493-1961
Practice Address - Street 1:15 PALOMBA DR
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3888
Practice Address - Country:US
Practice Address - Phone:860-493-1950
Practice Address - Fax:860-493-1961
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT67549207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008103991Medicaid
CTD400763432OtherMEDICARE