Healthcare Provider Details

I. General information

NPI: 1144632969
Provider Name (Legal Business Name): ANGIE PAIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CEDAR ST # BB330
NEW HAVEN CT
06510-3218
US

IV. Provider business mailing address

330 CEDAR ST # BB330
NEW HAVEN CT
06510-3218
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2772
  • Fax:
Mailing address:
  • Phone: 203-785-2772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberLP03168
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA168897
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number69545
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: