Healthcare Provider Details

I. General information

NPI: 1629074752
Provider Name (Legal Business Name): MAGDALENA G KRZYSTOLIK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RANDALL SQ SUITE 203
PROVIDENCE RI
02904-2709
US

IV. Provider business mailing address

1 RANDALL SQ SUITE 203
PROVIDENCE RI
02904-2709
US

V. Phone/Fax

Practice location:
  • Phone: 401-453-4600
  • Fax: 401-453-0077
Mailing address:
  • Phone: 401-453-4600
  • Fax: 401-453-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number153331
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD10368
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: