=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629077714
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOUSEIN M WAZAZ M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 LEWIS AVE SUITE 105
-----------------------------------------------------
City | MERIDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06451-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-237-2477
-----------------------------------------------------
Fax | 203-238-1839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 LEWIS AVE SUITE 105
-----------------------------------------------------
City | MERIDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06451-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-237-2477
-----------------------------------------------------
Fax | 203-238-1839
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 038168
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------