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General NPI Number Information
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NPI Number | 1891290516
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Entity Type | Individual
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Provider Name | KRISTOFER JOONDEPH-BREIDBART MD
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Gender | Male
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Dates
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Enumeration Date | 03/26/2018
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Last Update Date | 10/01/2022
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Provider Practice Location Address
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Address Line | 175 ELM ST
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City | SOMERVILLE
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State | MA
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Zip | 02144-3150
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Country | US
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Telephone | 617-804-7970
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Fax | 617-203-6011
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Provider Business Mailing Address
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Address Line | 32 MADISON ST # 2
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City | SOMERVILLE
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State | MA
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Zip | 02143-1209
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Country | US
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Telephone | 617-804-7970
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Fax | 617-203-6011
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 314147-01
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | A177531
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 288089
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License Number State | MA
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