Provider Demographics
NPI:1093991077
Name:ACEVEDO, YADIRA E (MD)
Entity Type:Individual
Prefix:
First Name:YADIRA
Middle Name:E
Last Name:ACEVEDO
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 1:13 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1616
Mailing Address - Country:US
Mailing Address - Phone:860-358-7100
Mailing Address - Fax:860-358-8321
Practice Address - Street 1:13 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:CT
Practice Address - Zip Code:06480-1616
Practice Address - Country:US
Practice Address - Phone:860-358-7100
Practice Address - Fax:860-358-8321
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT49520207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT49520OtherCT LICENSE