Healthcare Provider Details

I. General information

NPI: 1679278089
Provider Name (Legal Business Name): CLARISSA MAE DE JESUS VISTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

20 YORK ST
NEW HAVEN CT
06510-3220
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4242
  • Fax:
Mailing address:
  • Phone: 203-688-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number1.083879
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: