MEDICARE: NIKE ITOHAN KUBEYINJE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	MD036800	DC
2	208000000X	Pediatrics Physician	272823	NY
3	208000000X	Pediatrics Physician	ME108550	FL
4	208000000X	Pediatrics Physician	55255	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295922276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIKE ITOHAN KUBEYINJE MD

Provider Business Mailing Address
First Line	:	785 FARMINGTON AVENUE
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06119-1673
Country	:	US
Telephone Number	:	860-523-4100
Fax Number	:	860-523-1462

Provider Business Practice Location Address
First Line	:	785 FARMINGTON AVENUE
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06119-1673
Country	:	US
Telephone Number	:	860-523-4100
Fax Number	:	860-523-1462

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2007
Last Update Date	:	01/28/2022

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