Healthcare Provider Details

I. General information

NPI: 1285813311
Provider Name (Legal Business Name): REZA MOIEN MD INTERNAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N MAIN STREET EXT BUILDING#1, SUITE D2
WALLINGFORD CT
06492-2400
US

IV. Provider business mailing address

850 N MAIN STREET EXT BUILDING#1, SUITE D2
WALLINGFORD CT
06492-2400
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-0298
  • Fax: 203-265-0361
Mailing address:
  • Phone: 203-265-0298
  • Fax: 203-265-0361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number039581
License Number StateCT

VIII. Authorized Official

Name: DR. MOHAMMAD REZA MOIENAFSHARI
Title or Position: OWNER
Credential: M.D.
Phone: 203-265-0298