Provider Demographics
NPI:1306800099
Name:FARES, WASSIM H (MD, MSC)
Entity type:Individual
Prefix:
First Name:WASSIM
Middle Name:H
Last Name:FARES
Suffix:
Gender:M
Credentials:MD, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 YORK ST
Mailing Address - Street 2:LCI-105-C
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3221
Mailing Address - Country:US
Mailing Address - Phone:203-785-4196
Mailing Address - Fax:203-785-3634
Practice Address - Street 1:15 YORK ST
Practice Address - Street 2:LCI-105-C
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3221
Practice Address - Country:US
Practice Address - Phone:203-785-4196
Practice Address - Fax:203-785-3634
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050113207RP1001X, 207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2461894Medicaid