Basic Information
| Provider Information | |||||||||
| NPI: | 1346292711 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLKER | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 47 TOWN ST | ||||||||
| Address2: | |||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608927042 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 47 TOWN ST | ||||||||
| Address2: | |||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608927042 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 09/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A78919 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 52185 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100102890B | 05 | OK | MEDICAID | 008045537 | 05 | CT | MEDICAID |