Healthcare Provider Details

I. General information

NPI: 1972775039
Provider Name (Legal Business Name): BENJAMIN HALL ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2008
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 DIXWELL AVE PEDIATRICS
NEW HAVEN CT
06511-3456
US

IV. Provider business mailing address

400 COLUMBUS AVE CREDENTIALING
NEW HAVEN CT
06519-1233
US

V. Phone/Fax

Practice location:
  • Phone: 203-503-3420
  • Fax: 203-503-3422
Mailing address:
  • Phone: 203-503-3000
  • Fax: 203-503-3224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number064258
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number002538
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number687716
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: