Healthcare Provider Details

I. General information

NPI: 1093092165
Provider Name (Legal Business Name): EAST AVENUE PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 EAST AVE SUITE 1L
NORWALK CT
06851-5721
US

IV. Provider business mailing address

148 EAST AVE SUITE 1L
NORWALK CT
06851-5721
US

V. Phone/Fax

Practice location:
  • Phone: 203-854-6993
  • Fax: 203-854-9227
Mailing address:
  • Phone: 203-854-6993
  • Fax: 203-854-9227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number038173
License Number StateCT

VIII. Authorized Official

Name: DR. LIBIA RUEDA-MATIK
Title or Position: PHYSICIAN
Credential:
Phone: 203-854-6993