Healthcare Provider Details

I. General information

NPI: 1265964860
Provider Name (Legal Business Name): ASHWIN VAIDYANATHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2017
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 PARK AVE
TRUMBULL CT
06611-3463
US

IV. Provider business mailing address

333 CEDAR ST
NEW HAVEN CT
06510-3206
US

V. Phone/Fax

Practice location:
  • Phone: 203-261-7162
  • Fax:
Mailing address:
  • Phone: 203-785-2802
  • Fax: 203-785-6664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number70301
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number70301
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: