Healthcare Provider Details

I. General information

NPI: 1285862425
Provider Name (Legal Business Name): ERIN LONGBRAKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DEVINE ST SUITE 2B
NORTH HAVEN CT
06473-2195
US

IV. Provider business mailing address

300 GEORGE ST FL 6
NEW HAVEN CT
06511-6624
US

V. Phone/Fax

Practice location:
  • Phone: 203-287-6100
  • Fax: 203-287-6101
Mailing address:
  • Phone: 203-785-6610
  • Fax: 203-785-6414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2013005295
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2013005295
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number55076
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: