Healthcare Provider Details

I. General information

NPI: 1174013601
Provider Name (Legal Business Name): JAN PHILIPP BEWERSDORF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 PARK ST
NEW HAVEN CT
06519-1110
US

IV. Provider business mailing address

333 CEDAR ST
NEW HAVEN CT
06510-3206
US

V. Phone/Fax

Practice location:
  • Phone: 203-200-4363
  • Fax: 203-200-6385
Mailing address:
  • Phone: 203-688-9503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number75829
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: