Healthcare Provider Details

I. General information

NPI: 1548642283
Provider Name (Legal Business Name): BRIDGEPORT FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

754 CLINTON AVE
BRIDGEPORT CT
06604
US

IV. Provider business mailing address

112 SUNNYRIDGE AVE
FAIRFIELD CT
06824-4620
US

V. Phone/Fax

Practice location:
  • Phone: 203-243-6018
  • Fax:
Mailing address:
  • Phone: 203-243-6018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number049851
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number049851
License Number StateCT

VIII. Authorized Official

Name: AWAIS MALIK
Title or Position: MEDICAL DIRECTOR
Credential: M.D.,CEO
Phone: 203-243-6018