Provider Demographics
NPI:1194909572
Name:DITOLLA, KIMBERLY A (OD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:DITOLLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DITOLLA
Other - Last Name:PARTRIDGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:499 FARMINGTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1943
Mailing Address - Country:US
Mailing Address - Phone:860-678-0202
Mailing Address - Fax:860-678-0224
Practice Address - Street 1:499 FARMINGTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1943
Practice Address - Country:US
Practice Address - Phone:860-678-0202
Practice Address - Fax:860-678-0224
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2481152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004207347Medicaid
1619920592Medicare NSC
0714730002Medicare NSC
1598711723Medicare NSC
0714730001Medicare NSC
D400001054Medicare PIN
CT004207347Medicaid