Healthcare Provider Details

I. General information

NPI: 1376624106
Provider Name (Legal Business Name): EAST HAVEN PEDIATRICS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
EAST HAVEN CT
06512-2904
US

IV. Provider business mailing address

300 MAIN ST
EAST HAVEN CT
06512-2904
US

V. Phone/Fax

Practice location:
  • Phone: 203-469-8882
  • Fax: 203-467-9973
Mailing address:
  • Phone: 203-469-8882
  • Fax: 203-467-9973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. SHI-JEN CHENG
Title or Position: PRESIDENT PEDIATRICIAN
Credential: M.D.
Phone: 203-469-8882