1306116389 NPI number — DR. JOSE MANUEL PANISELLO MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306116389 NPI number — DR. JOSE MANUEL PANISELLO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANISELLO
Provider First Name:
JOSE
Provider Middle Name:
MANUEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1306116389
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 YORK STREET,
Provider Second Line Business Mailing Address:
LLCI 305 PEDIATRICS, YALE UNIVERSITY
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06520-8064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-785-4651
Provider Business Mailing Address Fax Number:
203-785-5833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 YORK ST
Provider Second Line Business Practice Location Address:
305 LCI
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06510-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-785-4651
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2012

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: 2080P0203X , with the licence number:  050338 , 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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