Provider Demographics
NPI:1265474787
Name:WHALEN, ELIZABETH ANN (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:WHALEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 KENNEDY DR
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-3096
Mailing Address - Country:US
Mailing Address - Phone:860-489-6718
Mailing Address - Fax:860-489-8270
Practice Address - Street 1:200 KENNEDY DR
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3096
Practice Address - Country:US
Practice Address - Phone:860-489-6718
Practice Address - Fax:860-489-8270
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT0327712085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001327718Medicaid