Healthcare Provider Details

I. General information

NPI: 1487369591
Provider Name (Legal Business Name): JOHN M WILLETT MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LONG WHARF DRIVE SUITE 302
NEW HAVEN CT
06511
US

IV. Provider business mailing address

1 LONG WHARF DRIVE SUITE 302
NEW HAVEN CT
06511
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7500
  • Fax: 203-777-8469
Mailing address:
  • Phone: 203-777-7500
  • Fax: 203-777-8469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELIZABETH SULLIVAN
Title or Position: PRACTICE MANGER
Credential:
Phone: 230-777-7500