Provider Demographics
NPI:1417955923
Name:WEST HAVEN MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WEST HAVEN MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANURUDDHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALALIYADDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-932-6481
Mailing Address - Street 1:687 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-3774
Mailing Address - Country:US
Mailing Address - Phone:203-932-6481
Mailing Address - Fax:203-932-4051
Practice Address - Street 1:687 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3774
Practice Address - Country:US
Practice Address - Phone:203-932-6481
Practice Address - Fax:203-932-4051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016797207QA0505X
CT016636207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty