Healthcare Provider Details

I. General information

NPI: 1104294644
Provider Name (Legal Business Name): WEST HAVEN PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 12/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

367 ELM ST
WEST HAVEN CT
06516-4217
US

IV. Provider business mailing address

367 ELM ST
WEST HAVEN CT
06516-4217
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-3227
  • Fax: 203-931-2848
Mailing address:
  • Phone: 203-932-3227
  • Fax: 203-931-2848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JOBEY JACOB
Title or Position: OWNER
Credential: MD
Phone: 203-932-3227