Healthcare Provider Details

I. General information

NPI: 1659431492
Provider Name (Legal Business Name): JESSICA LYNN MAGDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PECK RD
TORRINGTON CT
06790-6123
US

IV. Provider business mailing address

30 PECK RD
TORRINGTON CT
06790-6123
US

V. Phone/Fax

Practice location:
  • Phone: 860-482-8177
  • Fax: 860-482-6500
Mailing address:
  • Phone: 860-482-8177
  • Fax: 860-482-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042388
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: