Healthcare Provider Details

I. General information

NPI: 1629004452
Provider Name (Legal Business Name): DOUGLAS L IDELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LOCK ST
NEW HAVEN CT
06511-3603
US

IV. Provider business mailing address

55 LOCK ST
NEW HAVEN CT
06511-3603
US

V. Phone/Fax

Practice location:
  • Phone: 203-432-0206
  • Fax: 203-432-0072
Mailing address:
  • Phone: 203-432-0206
  • Fax: 203-432-0072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number039521
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: