Provider Demographics
NPI:1114055217
Name:NASADUKE, IRENE (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:NASADUKE
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 1:1150 SUMMER STREET
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5530
Mailing Address - Country:US
Mailing Address - Phone:203-357-0770
Mailing Address - Fax:
Practice Address - Street 1:1150 SUMMER STREET
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5530
Practice Address - Country:US
Practice Address - Phone:203-357-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028817207W00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
0100Z8817C701OtherANTHEM
CT001288176Medicaid
0100Z8817C701OtherANTHEM
A60629Medicare UPIN