Healthcare Provider Details

I. General information

NPI: 1871709063
Provider Name (Legal Business Name): MARIO RODENAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARIO RODENAS-MEDINA MD

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DEVINE ST STE 2B
NORTH HAVEN CT
06473-2222
US

IV. Provider business mailing address

6 DEVINE ST STE 2B
NORTH HAVEN CT
06473-2222
US

V. Phone/Fax

Practice location:
  • Phone: 203-287-6200
  • Fax:
Mailing address:
  • Phone: 203-287-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberME126080
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME126080
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number045989
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number045989
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: