Provider Demographics
NPI:1427045954
Name:BAZAZ-KAPOOR, RENU (DO)
Entity Type:Individual
Prefix:
First Name:RENU
Middle Name:
Last Name:BAZAZ-KAPOOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 WHITNEY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3691
Mailing Address - Country:US
Mailing Address - Phone:203-407-6410
Mailing Address - Fax:203-407-6433
Practice Address - Street 1:2200 WHITNEY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3691
Practice Address - Country:US
Practice Address - Phone:203-407-6410
Practice Address - Fax:203-407-6433
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041924207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001419242Medicaid
CT001419242Medicaid
CT110009135Medicare ID - Type Unspecified