Provider Demographics
NPI:1154577229
Name:DENEPITIYA-BALICKI, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:DENEPITIYA-BALICKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PERRYRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4608
Mailing Address - Country:US
Mailing Address - Phone:203-863-3000
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST # T-209
Practice Address - Street 2:YALE-NEW HAVEN HOSPITAL
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-2259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT052375207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program