Healthcare Provider Details

I. General information

NPI: 1114005501
Provider Name (Legal Business Name): KRISTINA JEAN POLLER D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINA JEAN RIDDLE D.O

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 WESTPARK DR KAISER PERMANENTE TYSONS CORNER MEDICAL CENTER
MC LEAN VA
22102-3109
US

IV. Provider business mailing address

2101 E JEFFERSON ST KAISER PERMANENTE MEDICARE ENROLLMENT
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 703-287-6400
  • Fax:
Mailing address:
  • Phone: 301-816-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberH0069445
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0102202776
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: