Healthcare Provider Details

I. General information

NPI: 1417659517
Provider Name (Legal Business Name): LAURA DIANEY IBANEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SEASIDE AVE
MILFORD CT
06460-4603
US

IV. Provider business mailing address

300 SEASIDE AVE
MILFORD CT
06460-4603
US

V. Phone/Fax

Practice location:
  • Phone: 204-876-4000
  • Fax:
Mailing address:
  • Phone: 203-876-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number83025
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: