Healthcare Provider Details

I. General information

NPI: 1003812421
Provider Name (Legal Business Name): MARY M TSE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

136 SHERMAN AVE STE 301
NEW HAVEN CT
06511-5210
US

IV. Provider business mailing address

136 SHERMAN AVE STE 301
NEW HAVEN CT
06511-5210
US

V. Phone/Fax

Practice location:
  • Phone: 203-776-7458
  • Fax: 203-776-2401
Mailing address:
  • Phone: 203-776-7458
  • Fax: 203-776-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number22781
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: