Healthcare Provider Details

I. General information

NPI: 1457490021
Provider Name (Legal Business Name): PAULA AMELIA MOYNAHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 E MAIN ST 4TH FLOOR
WATERBURY CT
06702-2310
US

IV. Provider business mailing address

141 E MAIN ST 4TH FLOOR
WATERBURY CT
06702-2310
US

V. Phone/Fax

Practice location:
  • Phone: 203-754-4125
  • Fax: 203-754-9407
Mailing address:
  • Phone: 203-754-4125
  • Fax: 203-754-9407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number014188
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: