Provider Demographics
NPI:1366423063
Name:FRAGOSO, CARLOS (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:FRAGOSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:A
Other - Last Name:VAZ FRAGOSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:950 CAMPBELL AVE
Mailing Address - Street 2:MAILCODE 151B
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-2770
Mailing Address - Country:US
Mailing Address - Phone:203-932-5711
Mailing Address - Fax:203-937-4932
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:MAILCODE 151B
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:203-937-4932
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026634207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1266345Medicaid
CT1266345Medicaid
CT110006974Medicare ID - Type Unspecified