Healthcare Provider Details

I. General information

NPI: 1336586502
Provider Name (Legal Business Name): SUSAN MARY O'MALLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

869 BOSTON POST RD
MADISON CT
06443-3144
US

IV. Provider business mailing address

869 BOSTON POST RD
MADISON CT
06443-3144
US

V. Phone/Fax

Practice location:
  • Phone: 203-520-3227
  • Fax:
Mailing address:
  • Phone: 203-520-3227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number035328
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: