1679906911 NPI number — DR. DECLAN T BARRY M.D.

Table of content: DR. DECLAN T BARRY M.D. (NPI 1679906911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679906911 NPI number — DR. DECLAN T BARRY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARRY
Provider First Name:
DECLAN
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1679906911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 LONG WHARF DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06511-5991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-781-4600
Provider Business Mailing Address Fax Number:
203-781-4624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 CONGRESS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06519-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-781-4600
Provider Business Practice Location Address Fax Number:
203-781-4624
Provider Enumeration Date:
08/09/2013

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: 103TC1900X , with the licence number:  2552 , 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)

  • Identifier: 004041000 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004082260 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004082286 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008022626 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008048393 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008003745 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008022622 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008001325 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500000315 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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