Healthcare Provider Details

I. General information

NPI: 1861667065
Provider Name (Legal Business Name): MICHELE SPENCER-MANZON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

333 CEDAR ST
NEW HAVEN CT
06510-3206
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2660
  • Fax: 203-785-3404
Mailing address:
  • Phone: 203-785-2660
  • Fax: 203-785-3404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number122192
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number122192
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207SG0202X
TaxonomyClinical Biochemical Genetics Physician
License Number2008-01116
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: