Provider Demographics
NPI:1407969686
Name:CZIBULKA, AGNES (MD)
Entity Type:Individual
Prefix:DR
First Name:AGNES
Middle Name:
Last Name:CZIBULKA
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 1:31 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2304
Mailing Address - Country:US
Mailing Address - Phone:203-234-1324
Mailing Address - Fax:203-239-3047
Practice Address - Street 1:31 BROADWAY
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2304
Practice Address - Country:US
Practice Address - Phone:203-234-1324
Practice Address - Fax:203-239-3047
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037603207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G95613Medicare UPIN