Healthcare Provider Details

I. General information

NPI: 1619134392
Provider Name (Legal Business Name): SUMA SHANKAR MAGGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WASHINGTON BLVD APT 1019
STAMFORD CT
06902-6844
US

IV. Provider business mailing address

40 CROSS ST FL 4
NORWALK CT
06851-4647
US

V. Phone/Fax

Practice location:
  • Phone: 617-784-5737
  • Fax:
Mailing address:
  • Phone: 203-845-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number051696
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number051696
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: