Healthcare Provider Details

I. General information

NPI: 1013272988
Provider Name (Legal Business Name): PATTI MUGO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SHAWS CV STE 103
NEW LONDON CT
06320-4956
US

IV. Provider business mailing address

1290 SILAS DEANE HWY FL 1
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-443-3778
  • Fax:
Mailing address:
  • Phone: 860-972-6970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51076
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number29375
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number066927
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: