Provider Demographics
NPI:1093092165
Name:EAST AVENUE PEDIATRICS PC
Entity Type:Organization
Organization Name:EAST AVENUE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LIBIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUEDA-MATIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-854-6993
Mailing Address - Street 1:148 EAST AVE
Mailing Address - Street 2:SUITE 1L
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5721
Mailing Address - Country:US
Mailing Address - Phone:203-854-6993
Mailing Address - Fax:203-854-9227
Practice Address - Street 1:148 EAST AVE
Practice Address - Street 2:SUITE 1L
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-5721
Practice Address - Country:US
Practice Address - Phone:203-854-6993
Practice Address - Fax:203-854-9227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038173208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001381730Medicaid