Healthcare Provider Details

I. General information

NPI: 1609052588
Provider Name (Legal Business Name): GEOFFREY MUKASA MUKWAYA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FAWNWOOD RD
SANDY HOOK CT
06482-1471
US

IV. Provider business mailing address

15 FAWNWOOD RD
SANDY HOOK CT
06482-1471
US

V. Phone/Fax

Practice location:
  • Phone: 203-364-1854
  • Fax: 646-441-6640
Mailing address:
  • Phone: 203-364-1854
  • Fax: 646-441-6640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number041978
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: