Provider Demographics
NPI:1235114794
Name:TINETTI, MARY E (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:TINETTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:789 HOWARD AVE
Mailing Address - Street 2:DANA BUILDING, 3RD FL
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1304
Mailing Address - Country:US
Mailing Address - Phone:203-688-6361
Mailing Address - Fax:203-688-4209
Practice Address - Street 1:789 HOWARD AVE
Practice Address - Street 2:DANA BUILDING, 3RD FL
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1304
Practice Address - Country:US
Practice Address - Phone:203-688-6361
Practice Address - Fax:203-688-4209
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT025669207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001256692Medicaid
CT001256692Medicaid
CT110001893Medicare ID - Type Unspecified