Provider Demographics
NPI:1063584787
Name:DEFUSCO, DIANNE JEAN (MD)
Entity type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:JEAN
Last Name:DEFUSCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2349
Mailing Address - Country:US
Mailing Address - Phone:203-234-6500
Mailing Address - Fax:203-234-6503
Practice Address - Street 1:2 BROADWAY
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2349
Practice Address - Country:US
Practice Address - Phone:203-234-6500
Practice Address - Fax:203-234-6503
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041834207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT041834OtherLICENSE
CTC02462Medicare PIN
CT110009704Medicare ID - Type Unspecified
CT041834OtherLICENSE