Healthcare Provider Details

I. General information

NPI: 1962847780
Provider Name (Legal Business Name): LACEY WHITMIRE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 02/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 HOWARD AVE ADULT PRIMARY CARE CENTER
NEW HAVEN CT
06519-1304
US

IV. Provider business mailing address

15 YORK ST LMP 1091B
NEW HAVEN CT
06510-3221
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-2984
  • Fax: 203-688-4092
Mailing address:
  • Phone: 203-785-7941
  • Fax: 203-785-3922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number56178
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: