1053574533 NPI number — DR. COLLEEN MARY PIETRAS M.D.

Table of content: DR. COLLEEN MARY PIETRAS M.D. (NPI 1053574533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053574533 NPI number — DR. COLLEEN MARY PIETRAS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PIETRAS
Provider First Name:
COLLEEN
Provider Middle Name:
MARY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053574533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 CEDAR STREET, BOARDMAN 204
Provider Second Line Business Mailing Address:
P.O. BOX 208041
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-785-5000
Provider Business Mailing Address Fax Number:
203-785-3346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 CEDAR STREET
Provider Second Line Business Practice Location Address:
BOARDMAN 204
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-785-5000
Provider Business Practice Location Address Fax Number:
203-785-3346
Provider Enumeration Date:
07/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  619412 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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