Healthcare Provider Details

I. General information

NPI: 1831785591
Provider Name (Legal Business Name): MARCO ABDO MOUANNESS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MAIN ST STE 101
WESTPORT CT
06880-3216
US

IV. Provider business mailing address

475 MAIN ST APT 2R
NEW YORK NY
10044-0084
US

V. Phone/Fax

Practice location:
  • Phone: 203-557-9696
  • Fax:
Mailing address:
  • Phone: 332-217-7997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number67160
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number67160
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number67160
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: