Provider Demographics
NPI:1437114071
Name:WAITZE, SEUNG-YEUN (MD,)
Entity Type:Individual
Prefix:DR
First Name:SEUNG-YEUN
Middle Name:
Last Name:WAITZE
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:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-0082
Mailing Address - Country:US
Mailing Address - Phone:203-262-6200
Mailing Address - Fax:203-262-6205
Practice Address - Street 1:22 POVERTY RD
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2254
Practice Address - Country:US
Practice Address - Phone:203-262-6200
Practice Address - Fax:203-262-6205
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038906174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001389065Medicaid
CT001389065Medicaid
CTC03456Medicare ID - Type UnspecifiedGROUP #