Provider Demographics
NPI:1285936559
Name:GENERAL MEDICAL PRACTICE OF WEST HAVEN LLC
Entity type:Organization
Organization Name:GENERAL MEDICAL PRACTICE OF WEST HAVEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MALLASETAPPA
Authorized Official - Middle Name:SHIRANNA
Authorized Official - Last Name:UMAPATHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-933-4001
Mailing Address - Street 1:309 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4424
Mailing Address - Country:US
Mailing Address - Phone:203-933-4001
Mailing Address - Fax:203-933-3759
Practice Address - Street 1:309 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4424
Practice Address - Country:US
Practice Address - Phone:203-933-4001
Practice Address - Fax:203-933-3759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025441208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT01000754Medicare UPIN