Healthcare Provider Details

I. General information

NPI: 1407023252
Provider Name (Legal Business Name): RENU RACHEL OUSEPH BOATRIGHT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 GRAND AVE
NEW HAVEN CT
06513-3733
US

IV. Provider business mailing address

374 GRAND AVE
NEW HAVEN CT
06513-3733
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7411
  • Fax: 203-777-8506
Mailing address:
  • Phone: 203-752-5248
  • Fax: 203-786-3004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number54222
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: