Healthcare Provider Details

I. General information

NPI: 1679701882
Provider Name (Legal Business Name): SOUTHERN CONNECTICUT GERIATRIC & PREVENTIVE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 LIVINGSTON ST
NEW HAVEN CT
06511-1336
US

IV. Provider business mailing address

390 LIVINGSTON ST
NEW HAVEN CT
06511-1336
US

V. Phone/Fax

Practice location:
  • Phone: 203-871-9224
  • Fax:
Mailing address:
  • Phone: 203-871-9224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number041288
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number041288
License Number StateCT

VIII. Authorized Official

Name: DR. ASEFEH HEIAT
Title or Position: MEMBER
Credential: M.D., M.P.H.
Phone: 203-871-9224