Healthcare Provider Details

I. General information

NPI: 1366768343
Provider Name (Legal Business Name): KATHLEEN JO ELAYDA CORBIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN JO FLORES ELAYDA

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CEDAR ST DCB 14
NEW HAVEN CT
06510-3218
US

IV. Provider business mailing address

333 CEDAR ST P.O. BOX 208064
NEW HAVEN CT
06510-3206
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-2475
  • Fax: 203-785-3932
Mailing address:
  • Phone: 203-688-2475
  • Fax: 203-785-3932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number55787
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: