Healthcare Provider Details

I. General information

NPI: 1356758387
Provider Name (Legal Business Name): IDAIRA AGUILAR TEJEDOR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 HAWLEY LN STE 1120
STRATFORD CT
06614-1208
US

IV. Provider business mailing address

99 HAWLEY LN STE 1120
STRATFORD CT
06614-1208
US

V. Phone/Fax

Practice location:
  • Phone: 203-377-5988
  • Fax:
Mailing address:
  • Phone: 203-377-5988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number64181
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number64181
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: