=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669736765
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAYANKA TICKOO M.D., M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2012
-----------------------------------------------------
Last Update Date | 05/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 CEDAR ST FL 4
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-737-1240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 YORK ST
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-3220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-737-1240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 60511
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 60511
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 265375
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------