Healthcare Provider Details

I. General information

NPI: 1407899073
Provider Name (Legal Business Name): MARK H. WEINSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 SHERMAN AVE #407
NEW HAVEN CT
06511-5238
US

IV. Provider business mailing address

136 SHERMAN AVE SUITE 407
NEW HAVEN CT
06511-5238
US

V. Phone/Fax

Practice location:
  • Phone: 203-624-0673
  • Fax:
Mailing address:
  • Phone: 203-624-0673
  • Fax: 203-907-4593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number018620
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: