=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508095308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NINANI EMANG KOMBO M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2009
-----------------------------------------------------
Last Update Date | 04/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 CHAPEL ST
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511-4421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-809-7677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 COLONY RD
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511-2811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-809-7677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 254235
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------