Healthcare Provider Details

I. General information

NPI: 1295716991
Provider Name (Legal Business Name): JAQUELINE BUZA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GAYLORD FARMS RD.
WALLINGFORD CT
06492
US

IV. Provider business mailing address

GAYLORD FARMS RD. PO BOX 400
WALLINGFORD CT
06492
US

V. Phone/Fax

Practice location:
  • Phone: 203-284-2800
  • Fax: 203-679-3598
Mailing address:
  • Phone: 203-284-2800
  • Fax: 203-679-3598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number024312
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: