Healthcare Provider Details

I. General information

NPI: 1417955923
Provider Name (Legal Business Name): WEST HAVEN MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 CAMPBELL AVE
WEST HAVEN CT
06516-3774
US

IV. Provider business mailing address

687 CAMPBELL AVE
WEST HAVEN CT
06516-3774
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-6481
  • Fax: 203-932-4051
Mailing address:
  • Phone: 203-932-6481
  • Fax: 203-932-4051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number016797
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number016636
License Number StateCT

VIII. Authorized Official

Name: DR. ANURUDDHA WALALIYADDA
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 203-932-6481