Healthcare Provider Details

I. General information

NPI: 1285130112
Provider Name (Legal Business Name): IMAN KHADIJA BERRAHOU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2018
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CEDAR ST
NEW HAVEN CT
06510-3206
US

IV. Provider business mailing address

333 CEDAR ST
NEW HAVEN CT
06510-3206
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-5188
  • Fax:
Mailing address:
  • Phone: 203-785-5188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number71775
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: