Healthcare Provider Details

I. General information

NPI: 1942865563
Provider Name (Legal Business Name): KENAN TAWAKLNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CEDAR ST
NEW HAVEN CT
06510-3218
US

IV. Provider business mailing address

330 CEDAR ST
NEW HAVEN CT
06510-3218
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2571
  • Fax:
Mailing address:
  • Phone: 203-785-2571
  • Fax: 203-785-5714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number1023780
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: