Provider Demographics
NPI:1417485830
Name:WINDHAM, MARY RUTH (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:RUTH
Last Name:WINDHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 E MAIN ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2971
Mailing Address - Country:US
Mailing Address - Phone:203-488-5885
Mailing Address - Fax:
Practice Address - Street 1:688 E MAIN ST STE 1A
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2971
Practice Address - Country:US
Practice Address - Phone:203-488-5885
Practice Address - Fax:203-488-5899
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT64905207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty