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General NPI Number Information
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NPI Number | 1578659827
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Entity Type | Organization
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Legal Business Name | CONNECTICUT EYECARE CENTER PC
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 46 PRINCE STREET SUITE 202
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City | NEW HAVEN
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State | CT
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Zip | 06519
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Country | US
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Telephone | 203-562-2106
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Fax | 203-787-5914
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Provider Business Mailing Address
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Address Line | 46 PRINCE STREET SUITE 202
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City | NEW HAVEN
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State | CT
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Zip | 06519
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Country | US
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Telephone | 203-562-2106
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Fax | 203-787-5914
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Authorized Official
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Title or Position | OWNER DIRECTOR
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Name | DR. ALI A KHODADOUST
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Credential | MD
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Telephone | 203-562-2106
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 030415
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License Number State | CT
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