Provider Demographics
NPI:1114011343
Name:MALEFATTO, JERRY P (MD)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:P
Last Name:MALEFATTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CORPORATE DRIVE
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611
Mailing Address - Country:US
Mailing Address - Phone:203-459-0262
Mailing Address - Fax:203-459-0264
Practice Address - Street 1:15 CORPORATE DRIVE
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611
Practice Address - Country:US
Practice Address - Phone:203-459-0262
Practice Address - Fax:203-459-0264
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031058207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
25464OtherOXFORD
CT010031058CT01OtherANTHEM
CT001310581Medicaid
001410OtherHEALTHNET
CT440000032Medicare ID - Type Unspecified
25464OtherOXFORD