Provider Demographics
NPI:1215936083
Name:NUSSBAUM, PAUL BARRY (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:BARRY
Last Name:NUSSBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 MADISON AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5534
Mailing Address - Country:US
Mailing Address - Phone:203-335-0195
Mailing Address - Fax:203-335-7293
Practice Address - Street 1:900 MADISON AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5534
Practice Address - Country:US
Practice Address - Phone:203-335-0195
Practice Address - Fax:203-335-7293
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT020563207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001205632Medicaid
CT390003274Medicare PIN
CTC59752Medicare UPIN
CT001205632Medicaid