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General NPI Number Information
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NPI Number | 1275972952
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Entity Type | Individual
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Provider Name | ANNETTE VANNILAM MD
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Gender | Female
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Dates
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Enumeration Date | 06/17/2013
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Last Update Date | 09/04/2024
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Provider Practice Location Address
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Address Line | 191 POST RD W
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City | WESTPORT
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State | CT
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Zip | 06880-4625
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Country | US
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Telephone | 860-545-9560
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Fax |
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Provider Business Mailing Address
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Address Line | 191 POST RD W
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City | WESTPORT
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State | CT
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Zip | 06880-4625
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Country | US
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Telephone | 860-545-9560
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 4301103398
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 2080P0206X
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Taxonomy Name | Pediatric Gastroenterology Physician
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License Number | MD0000054575
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 4301103398
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 2080P0206X
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Taxonomy Name | Pediatric Gastroenterology Physician
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License Number | 75930
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License Number State | CT
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