Provider Demographics
NPI:1992066294
Name:SOLTANPOUR, KRISTINE (DO)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:SOLTANPOUR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4034
Mailing Address - Country:US
Mailing Address - Phone:315-779-5244
Mailing Address - Fax:
Practice Address - Street 1:1129 NORTHERN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3022
Practice Address - Country:US
Practice Address - Phone:516-365-5570
Practice Address - Fax:516-365-5532
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY296598207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program