Healthcare Provider Details

I. General information

NPI: 1962760348
Provider Name (Legal Business Name): MARIELA JOSE MORALES JIMENEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

447 NAUBUC AVE STE 112
GLASTONBURY CT
06033-1075
US

IV. Provider business mailing address

447 NAUBUC AVE STE 112
GLASTONBURY CT
06033-1075
US

V. Phone/Fax

Practice location:
  • Phone: 860-266-4686
  • Fax: 860-266-4688
Mailing address:
  • Phone: 860-266-4686
  • Fax: 860-266-4688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number067074
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: