Healthcare Provider Details

I. General information

NPI: 1962845917
Provider Name (Legal Business Name): PAVEL TESLYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 MAIN STREET
BRIDGEPORT CT
06606-4201
US

IV. Provider business mailing address

2800 MAIN ST
BRIDGEPORT CT
06606-4201
US

V. Phone/Fax

Practice location:
  • Phone: 203-576-5764
  • Fax: 203-576-5263
Mailing address:
  • Phone: 203-863-3911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number55615
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: