=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194771790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW HAVEN OPHTHALMOLOGY ASSOCIATES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 ORANGE ST
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511-6202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-865-8002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 ORANGE ST
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511-6202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-865-8002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | VANESSA ANN BERGEVIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-865-8002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------