Provider Demographics
NPI:1194110189
Name:MACCALLUM, KATHERINE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:MACCALLUM
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 1:2 DUDLEY ST STE 470
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-3248
Mailing Address - Country:US
Mailing Address - Phone:401-553-8325
Mailing Address - Fax:401-868-2336
Practice Address - Street 1:2 DUDLEY ST STE 470
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3248
Practice Address - Country:US
Practice Address - Phone:401-553-8325
Practice Address - Fax:401-868-2336
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2934412086S0129X
NY390200000X
390200000X
RIMD184732086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program