Healthcare Provider Details

I. General information

NPI: 1174711741
Provider Name (Legal Business Name): MAI KONG XIONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 S MAIN ST
MIDDLETOWN CT
06457-3649
US

IV. Provider business mailing address

28 AVON CT
MIDDLETOWN CT
06457-4521
US

V. Phone/Fax

Practice location:
  • Phone: 860-344-6300
  • Fax: 860-344-9249
Mailing address:
  • Phone: 860-344-9571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number045864
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: