Healthcare Provider Details

I. General information

NPI: 1619186574
Provider Name (Legal Business Name): BRANFORD NORTH BRANFORD PEDIATRICS,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 FOXON RD
NORTH BRANFORD CT
06471-1287
US

IV. Provider business mailing address

682 E MAIN ST
BRANFORD CT
06405-2907
US

V. Phone/Fax

Practice location:
  • Phone: 203-484-7334
  • Fax: 203-484-7301
Mailing address:
  • Phone: 203-481-5591
  • Fax: 203-481-5594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. LINDA A. WALDMAN
Title or Position: PRESIDENT
Credential:
Phone: 203-481-5591