Healthcare Provider Details

I. General information

NPI: 1386618692
Provider Name (Legal Business Name): AUGUSTE H FORTIN VI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 CHAPEL ST ADULT PRIMARY CARE CENTER
NEW HAVEN CT
06511-4405
US

IV. Provider business mailing address

1450 CHAPEL ST ADULT PRIMARY CARE CENTER
NEW HAVEN CT
06511-4405
US

V. Phone/Fax

Practice location:
  • Phone: 203-789-4044
  • Fax: 203-789-3007
Mailing address:
  • Phone: 203-789-4094
  • Fax: 203-789-3007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number034714
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: