Healthcare Provider Details

I. General information

NPI: 1780676023
Provider Name (Legal Business Name): NEIL W TISHKOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CEDAR ST STE TE2
NEW HAVEN CT
06510-3206
US

IV. Provider business mailing address

333 CEDAR ST STE TE2
NEW HAVEN CT
06510-3206
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-3067
  • Fax: 203-200-5170
Mailing address:
  • Phone: 203-785-3067
  • Fax: 203-200-5170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number37744
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number037744
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: