Healthcare Provider Details

I. General information

NPI: 1407387715
Provider Name (Legal Business Name): RICKY AYALA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 RETREAT AVE
HARTFORD CT
06106
US

IV. Provider business mailing address

79 RETREAT AVE
HARTFORD CT
06106-2527
US

V. Phone/Fax

Practice location:
  • Phone: 860-972-0200
  • Fax: 860-545-3149
Mailing address:
  • Phone: 860-972-0200
  • Fax: 860-545-3149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number68247
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: