=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639152721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAIDEEP SHRIRANG TALWALKAR MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2005
-----------------------------------------------------
Last Update Date | 11/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 YORK ST YNHH WEST PAVILION, 2ND FL
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-3220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-688-1947
-----------------------------------------------------
Fax | 203-688-8580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 YORK ST YNHH WEST PAVILION, 2ND FL
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-3220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-688-1947
-----------------------------------------------------
Fax | 203-688-8580
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 042413
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------