Provider Demographics
NPI:1811976319
Name:SELF, KATHRYN CABOT (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CABOT
Last Name:SELF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 BROOKDALE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-4543
Mailing Address - Country:US
Mailing Address - Phone:276-666-7545
Mailing Address - Fax:276-632-0912
Practice Address - Street 1:1109 BROOKDALE ST
Practice Address - Street 2:SUITE C
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-4543
Practice Address - Country:US
Practice Address - Phone:276-666-7545
Practice Address - Fax:276-632-0912
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101227849208000000X
UT7725550-8017208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1811976319Medicaid
UTU000070907Medicare PIN