Healthcare Provider Details

I. General information

NPI: 1003005703
Provider Name (Legal Business Name): INTERNAL MEDICINE OF WEST HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 CAMPBELL AVE SUITE E
WEST HAVEN CT
06516-3786
US

IV. Provider business mailing address

764 CAMPBELL AVE
WEST HAVEN CT
06516-3786
US

V. Phone/Fax

Practice location:
  • Phone: 203-931-0034
  • Fax: 203-931-8225
Mailing address:
  • Phone: 203-931-0034
  • Fax: 203-931-8225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARIZELLE FLORES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 860-944-4766