Healthcare Provider Details

I. General information

NPI: 1346202371
Provider Name (Legal Business Name): DEENA RACHEL EBRIGHT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEENA RACHEL FORMAN M.D.

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 GROVE ST 1ST FLOOR
NEW CANAAN CT
06840-5329
US

IV. Provider business mailing address

36 GROVE ST 1ST FLOOR
NEW CANAAN CT
06840-5329
US

V. Phone/Fax

Practice location:
  • Phone: 203-966-6305
  • Fax: 203-966-4618
Mailing address:
  • Phone: 203-966-6305
  • Fax: 203-966-4618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number052517
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: